i

STUDY OF URINARY URIC ACID AND CREATININE

RATIO AS A MARKER OF NEONATAL ASPHYXIA


By
Dr.SHETTY YUVARAJA SHASHIDHARA, MBBS

Dissertation Submitted to the
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore, in partial
fulfillment of the requirements for the degree of

DOCTOR OF MEDICINE
IN
PEDIATRICS

Under the guidance of
Dr. SHIVAPRAKASH N.C
MBBS, MD

PROFESSOR AND H.O.D

DEPARTMENT OF PEDIATRICS,
ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES,
B.G. NAGARA, NAGAMANGALA TALUK, MANDYA DIST. KARNATAKA


2012
ii

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled STUDY OF
URINARY URIC ACID AND CREATININE RATIO AS A MARKER OF
NEONATAL ASPHYXIA is a bonafide and genuine research work carried out by
me under the guidance of Dr. SHIVAPRAKASH N.C MBBS, MD, Professor and Head
of the Department of Pediatrics, Adichunchanagiri Institute of Medical Sciences,
B.G. Nagara, Nagamangala Taluk, Mandya District, Karnataka.
I submit this dissertation to Rajiv Gandhi University of Health Sciences,
Bangalore, Karnataka, in partial fulfillment of the regulation for the award of the
degree of Doctor of Medicine in Pediatrics.
This dissertation has not been submitted to any other University for the award
of any degree or diploma.




iii


CERTIFICATE BY THE GUIDE
This is to certify that this dissertation titled STUDY OF URINARY URIC
ACID AND CREATININE RATIO AS A MARKER OF NEONATAL
ASPHYXIA is a bonafide research work done by Dr. SHETTY YUVARAJA
SHASHIDHARA, Postgraduate student, Department of Pediatrics, Adichunchanagiri
Institute of Medical Sciences, B.G. Nagara, Nagamangala Taluk, Mandya District,
Karnataka, in partial fulfillment of the requirement for the degree of Doctor of
Medicine in Pediatrics.



iv


RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE

ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE
INSTITUTION
This is to certify that this dissertation entitled STUDY OF URINARY URIC
ACID AND CREATININE RATIO AS A MARKER OF NEONATAL
ASPHYXIA is a bonafide research work done by Dr. SHETTY YUVARAJA
SHASHIDHARA, Postgraduate Student in Pediatrics, Adichunchanagiri Institute of
Medical Sciences, B.G. Nagara, Mandya Disrtict, Karnataka, under the guidance of
Dr. SHIVAPRAKASH N.C.
MBBS, MD.,
Professor and Head of the Department,
Department of Pediatrics, Adichunchanagiri Institute of Medical Sciences, B.G.
Nagara, Mandya District. Karnataka, in partial fulfillment of the requirement for the
degree of Doctor of Medicine in Pediatrics.

v

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE

COPYRIGHT
DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences,
Karnataka, shall have all rights to preserve, use and disseminate this
dissertation/thesis in print or electronic format for the academic/ research purpose.




Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore
vi

ACKNOWLEDGEMENT
With great reverence, I extend my deep sense of gratitude to my respected
guide and teacher Dr. SHIVAPRAKASH N.C.
MD,
Professor and Head of the
Department, Department of Pediatrics, Adichunchanagiri Institute of Medical
Sciences, B.G. Nagara, for his advice and able guidance, constant inspiration,
constructive criticism and novel sugesstions, without whose initiative and enthusiasm,
this study would not have been completed.
I extend my sincere thanks to Dr. VENKATAMURTHY. M.
MD,
Professor of
Pediatrics, Adichunchanagiri Institute of Medical Sciences, B.G. Nagara, for his
valuable guidance, encouragement and suggestion during this dissertation.
I would like to thank Dr, M.G. SHIVARAMU, THE PRINCIPAL,
Adichunchanagiri Institute of Medical Sciences, B.G. Nagara, for permitting me to
utilize the college and hospital facilities for the study.
I sincerely thank Dr. VIJAYADEVA, Dr. SUGUNA, Dr. VIJAYKUMAR,
Dr. SRINIVAS and Dr. SUNIL for their constant encouragement and guidance.
I also sincerely thank Dr. PRASANNA KUMAR, Former Associate
Professor of Pediatrics, Adichunchanagiri Institute of Medical Sciences, B.G. Nagara,
Dr. AMIT MISRI, Dr. JAYA KUMAR, Dr. NARENDRA and Dr. APARNA who
had guided me directly or indirectly during the study.
I would like to thank my colleague Dr. RAHUL MAJUMDAR for his
support and encouragement.
vii

I thank my fellow postgraduates students Dr. GAURAV, Dr. ADITI,
Dr PREKSHYA, Dr. GOLDIE for their help and suggestions during this work.
I thank Dr.K.P.Suresh, Scientist (Biostatistics) for his valuable support in the
statistical analysis.
I also thank M/s. Madhu Computers for editing and processing of this
dissertation.
I will be failing in my duty, if I do not express my gratitude to all those
neonates who were the subjects of this study.
Finally, I would like to thank Almighty God, my parents
Mr. B. SHASHIDHARA SHETTY and Mrs. SARVAJNHE SHETTY, my brother
KEITAN SHETTY whose constant blessings, inspiration and support have been with
me always.



viii

ABSTRACT
BACKGROUND AND OBJECTIVES
Perinatal asphyxia is a devastating clinical condition because of its potential
for causing permanent damage and even death of the fetus or newborn infant.
Perinatal asphyxia is a common neonatal problem and contributes significantly to
neonatal morbidity and mortality. Only a third of deliveries in India are institutional
and many asphyxiated babies are brought late to hospitals. In the absence of perinatal
records, it is difficult to retrospectively diagnose perinatal asphyxia. There is a need to
identify neonates with asphyxia who will be at high risk for hypoxic ischemic
encephalopathy and multi-organ dysfunction.
The value of the present biochemical parameters for diagnosing asphyxia is
inadequate and controversial. The main objective of this study was to evaluate
prospectively the value of measuring uric acid to creatinine (UA/Cr) ratio in early
spot urine samples in diagnosing perinatal asphyxia, and to assess the
relationship between the urinary UA/Cr ratio and the severity of HIE.
METHODS
A study was conducted on 50 neonates comprising the cases and 50 neonates
comprising the controls meeting the inclusion and exclusion criteria born in
Adichunchanagiri Instiute Medical Sciences and Research Centre, B.G.Nagara from
December 2009 to November 2010. Cases and Controls comprised of asphyxiated
and non-asphyxiated neonates, respectively. The spot urine samples were collected
within 6-24 hours of life and sent for analysis. A cut-off urinary uric acid to
creatinine (UA/Cr) ratio value of >1.14 was taken as the cut-off level. The
ix

sensitivity, specificity, Positive predictive value (PPV), Negative predictive value
(NPV) was calculated.
RESULTS
The Urinary UA/Cr ratios were found to be higher in asphyxiated infants
(2.581.09) when compared with those in the controls (0.860.17, P<0.001). UA/Cr
ratios were significantly higher in infants with severe HIE (Stage 3) (4.370.43) when
compared with infants with moderate HIE (Stage 2) (2.900.56) and those with mild
HIE (Stage 1) (2.700.66). A significant correlation was also detected between the
UA/Cr ratio and the severity of HIE in the asphyxiated group (r =0.963, P <
0.001).The cut-off UAA/Cr value of >1.14 has 84% sensitivity with a specificity of
94% and has a positive predictive value of 93.33% with a negative predictive value of
85.45%.With an accuracy of 89%.
INTERPRETATION AND CONCLUSION
The urinary uric acid/creatinine ratio was found to be a good, early, simple and
reliable screening test for the early diagnosis and assessment of perinatal asphyxia.
KEY WORDS
Perinatal asphyxia, urinary uric acid / creatinine ratio ,hypoxic ischemic
encephalopathy (HIE)
x

LIST OF ABBREVIATION

6-PG - 6 - Phospho Gluconate
ADP - Adenosine - 5- diphosphate
ALT - Alanine aminotransferase
ARF - Acute Renal Failure
AST - Aspartate aminotransferase
ATP - Adenosine - 5- triphosphate
AUROC - Area Under Receiving operating Characteristic.
Bpm - Beats/minute
CCF - Congestive Cardiac Failure
CFM - Cerebral Function Monitoring
CI - Confidence Interval
CK - Creatine Kinase
CK-BB - Creatine Kinase-Brain Bound
CK-MB - Creatine Kinase Muscle-Brain
CNS - Central nervous system
CP - Cerebral palsy
CT - Computed Tomography
CTG - Cardiotocograph
CTnT - Cardiac Troponin T
DAMA - Discharge Against Medical Advice
DIC - Disseminated Intravascular Coagulation
DWI - Diffusion Weighted Imaging
EEG - Electroencephalogram
xi

G-6-P - Glucose - 6 - Phosphate
G-6-P DH - Glucose - 6 Phosphate Dehydrogenase
HI - Hypoxia-Ischemia
HIE - Hypoxic Ischemic Encephalopathy
HK - Hexokinase
ICD - International Classification of Diseases
ICP - Intracranial Pressure
LDH - Lactate Dehydrogenase
MOD - Multi-Organ Dysfunction
MRI - Magnetic Resonance Imaging
MSAF - Meconium Stained Amniotic Fluid
NAD
+
-

Nicotinamide Adenine Dinucleotide
NADH - Reduced Nicotinamide Adenine Dinucleotide

NADP+ - Nicotinamide Adenine Dinucleotide Phosphate
NADPH - Reduced Nicotinamide Adenine Dinucleotide Phosphate
NICU - Neonatal Intensive Care Unit
NNPD - National Neonatal Perinatal Database
NPV - Negative Predictive Value
NST - Non Stress Test
PCr - Phosphocreatine
PPV - Positive Predictive Value
RD - Respiratory Distress
ROC - Receiver Operator Characteristics
TMI - Transient Myocardial Ischemia
WHO - World Health Organization
UUA - Urinary Uric Acid
xii

CR - Creatinine
UUA/CR - Urinary Uric Acid and Creatinine Ratio
UA : Uric acid
CRP : C reactive protein
Nacl : Sodium chloride
PA : Perinatal asphyxia
CSF : Cerbro spinal fluid
xiii

TABLE OF CONTENTS
S.No. TITLE PAGE No.
1. INTRODUCTION 1
2. AIMS AND OBJECTIVES 5
3. REVIEW OF LITERATURE 6
4. METHODOLOGY 71
5. OBSERVATION AND RESULTS 82
6. DISCUSSION 113
7. SUMMARY 125
8. CONCLUSION 131
9. BIBLIOGRAPHY 133
10. ANNEXURE 145

PROFORMA


KEY TO MASTER CHART


MASTER CHART

xiv

LIST OF TABLES
SL.NO Tables Page No
1 Apgar Evaluation of Newborn Infants 24
2 Factors Affecting the Apgar Score 25
3
Incidence of Neonatal Death in 132, 228 Singleton Infants Born at
Term (37th wk of Gestation or Later) in Relation to Apgar Scores at
5 min of Age
27

4

Risk of death or cerebral palsy(CP) in infants >2500g with Apgar
scores 0-3 at varying times from birth
27

5

Clinical Criteria Necessary to Establish That Acute Neurological
Injury in the Newborn Was Related to "Asphyxia" Proximate to
Delivery.
29
6

Important physiological adaptations to short episodes of fetal
hypoxic stress.
32

7 Sarnat and Sarnat Stages of Hypoxic-Ischemic Encephalopathy. 36
8

A clinical grading system for hypoxic-ischaemic encephalopathy
byLevene MI.
38

9 Differential diagnosis of hypoxic-ischaemic encephalopathy. 40
10

Risk of death or severe handicap in remaining survivors associated
with grade of HIE.
42

11 Multiorgan Systemic Effects of Asphyxia. 45
12
Criteria for organ dysfunction in newborn infants with perinatal
asphyxia used by Shah et al. 2004
48
13
Markers of hypoxia/stress in the neonate as a result of normal
labour.
52
xv


14

Factors other than asphyxia that may delay the onset of respiration
after delivery.
53

15 Gender distribution of neonates studied 82
16 Gestational age distribution of neonates studied 84
17 Birth weight of neonates studied 85
18 Maternal History of neonates studied 86
19 Mode of delivery of neonates studied 87
20 Presenting part at the time of delivery of neonates studied 88
21 Signs of Fetal Distress of neonates studied 89
22 Apgar score of neonates studied 91
23 Table 23: Apgar score further subdivided of neonates studied 92
24
Resuscitation with >1 minute of positive pressure ventilation
required for the neonates studied
96
25 showing the arterial pH of the neonates studied 97
26 Neurological Examination of the neonates studied 98
27

Incidence of HIE (HYPOXIC ISCHEMIC ENCEPHALOPATHY)
amoung neonates studied
100

28

Outcome of neonates enrolled in the case group having suffered
asphyxia
101
29 Comparison of UUA/Cr ratio in two groups studied 102
30 Correlation of clinical variables with HIE status in cases studied 103
31
Correlation of urinary uric acid and creatinine ratio(UUA/Cr) with
HIE status in cases studied
108
32 Correlation of Apgar score with HIE status in cases studied 109
xvi


33
Shows sensitivity, specificity and predictive values of UAA/Cr in
prediction of Neo-natal asphyxia
112

34
Comparative study of baseline characteristics of cases and
controls.between our study an as reported by Reem Mahmoud and
Dina El Abd(42)
116


35
The urinary uric acid / creatinine ratio in relation to HIE reported by
Reem Mahmoud and Dina El Abd(42)
117

36 Correlation of UAA/Cr with HIE status in our case 117
37
Comparative study of baseline characteristics of cases and
controls.between our study an as reported by Pallab Basu et al
118
38
:Comparative study of baseline characteristics of cases and
controls.between our study an as reported by BADER et al
119
39
Comparative study of results of our study an as reported by
BADER et al (39)
120
40
Comparative study of results of our study an as reported by CHEN
et al (36)
120




xvii

LIST OF FIGURE
Sl.No Figure Page No
1 Estimated distribution of direct causes of 4 million neonatal
deaths for the year 2000
16
2 Redistribution of cardiac output during HI in fetal lamb 34
3 The principal cellular and biochemical sites of damage in cell
injury. Mitochondrial damage may lead to reversible injury and
death by necrosis or apoptosis.
49
4 Schematic summary of mechanisms involved in hypoxia-
ischemia induced cellular injury.
50
5 Mechanisms of membrane damage in cell injury. 51
6 Physiological changes during asphyxia and resuscitation of
newborn animal.
57
7 Shows gender distribution of neonates studied. 83
8 shows gestational age distribution of neonates studied 84
9 Shows birth weight distribution of neonates studied. 85
10 Shows maternal history of neonates studied 86
11 showing the mode of delivery of the neonates studied 87
12 showing the NST(non stress test) of the neonates studied 89
13 showing the mode of delivery of the neonates studied 90
14 showing the APGAR score at 1 minute of the neonates studied 93
15 showing the APGAR score at 5 minutes of the neonates studied 94
16 showing the APGAR score at 10 minutes of the neonates studied 95
17 showing the need for resuscitation of the neonates studied 96
18 showing the arterial pH of the neonates studied 97
19 showing the tone of neonates studied 98
xviii

20 showing the number of neonates studied havin seizures 99
21 showing HIE staging of asphyxiated neonates 100
22 showing outcome of asphyxiated neonates 101
23 Comparison of UUA/Cr ratio in two groups studied 102
24 Correlation of maternal history with HIE status in cases studied 104
25 Correlation of gestational HIE status in cases studied 104
26 non stress test whether reactive or non reactive which is an
indicator of fetal distress with HIE status in cases studied
105
27 Correlation of thick meconium staining of liquor which is an
indicator of fetal distress with HIE status in cases studied
106
28 Correlation of ABG (arterial pH) with HIE status in cases
studied
106
29 Correlation of outcome of cases with HIE status in cases studied 107
30 Comparison of urinary uric acid and creatinine ratio(UUA/Cr)
with HIE status in cases studied
108
31 Correlation of Apgar score at 1 min with HIE status in cases
studied
110
32 Correlation of Apgar score at 5 min with HIE status in cases
studied
110
33 Correlation of Apgar score at 10 min with HIE status in cases
studied
111
34 ROC analysis of UAA/Cr to prediction of Neo-natal asphyxia 112




1

INTRODUCTION
Perinatal asphyxia is a common neonatal problem and contributes significantly
to neonatal morbidity and mortality. Globally, hypoxia of the newborn (birth
asphyxia) or the fetus ("fresh stillbirth") is estimated to account for 23% of the 4
million neonatal deaths and 26% of the 3.2 million stillbirths each year
1
. An estimated
1 million children who survive birth asphyxia live with chronic neurodevelopmental
morbidities, including cerebral palsy, mental retardation, and learning disabilities.
Every hour, 104 children die as a result of asphyxia
1
. That is, approximately 8% of the
total global pediatric mortality (age less than five years) making it a serious problem.
Due to a lack of resources, developing countries are more effected. Yet this a global
issue requiring urgent attention.
In India, between 250,000 to 350,000 infants die each year due to birth
asphyxia, mostly within the first three days of life
2
. Data from National Neonatal
Perinatal database (NNPD) suggests that perinatal asphyxia contributes to almost 20%
of neonatal deaths in India
2
. In addition, ante-partum and intra-partum asphyxia
contributes to as many as 300,000 to 400,000 stillbirths
2
. In India, 8.4% of inborn
babies have a one minute Apgar score less than 7 and 1.4% suffer from hypoxic
ischemic encephalopathy (HIE)
2
.
2).
Accurate estimates of the proportion of neonatal
mortality attributable to birth asphyxia are limited by the lack of a consistent
definition for use in community-based settings and the absence of vital registration in
communities where the majority of neonatal deaths occur.
Only a third of deliveries in India are institutional
3
and many asphyxiated
babies are brought late to hospitals. The signs of asphyxial injury are nonspecific and
2

overlap with other illnesses. In the absence of perinatal records, it is difficult to

retrospectively diagnose perinatal asphyxia.
Although asphyxia is associated with multiple organ injuries, especially with
adverse neurological outcomes, management still focuses on supportive care. So, if
the adverse effects of hypoxia on the newborn are considered, there is a need to
identify infants who will be at high risk for hypoxic ischemic encephalopathy and
early neonatal death as a consequence of perinatal hypoxia. A variety of markers have
been examined to identify perinatal hypoxia including electronic fetal heart
monitoring, low Apgar scores, cord pH, electroencephalograms (EEG), computed
tomography (CT) and magnetic resonance imaging (MRI) scans and Doppler flow
studies. The current problem, then becomes our inability to precisely distinguish the
false positive affected from the true positive asphyxiated or compromised fetus.
Several studies have been conducted to evaluate better markers that help distinguish
an asphyxiated from a non-asphyxiated neonates.
Perinatal asphyxia may result in adverse effects on all major body systems.
Many of these complications are potentially fatal. In a term infant with perinatal
asphyxia renal, neurologic, cardiac and lung dysfunction occurs in 50%, 28%, 25%
and 23% cases respectively
4
. The extent of multi-organ dysfunction (MOD)
determines the early outcome of an asphyxiated neonate with either the neonate
succumbing as a consequence of organ damage or recovering completely. Generally
there are no long term sequelae associated with these organ system derangements.
HIE refers to the central nervous system (CNS) dysfunction associated with perinatal
asphyxia.HIE is the foremost concern in asphyxiated neonate because contrary 2 other
3

system derangements this has the potential to cause serious long term neuromotor
sequel among survivors.
The neuro-developmental delay cannot be assessed with currently used
diagnostic methods in patients with neonatal asphyxia or HIE.
5,6,7

Neonatal asphyxia causes neurological morbidity and mortality in full term
infants. Despite the increasing understanding of the mechanisms leading to and
resulting from neonatal asphyxia, early determination of brain damage following
hypoxic-ischemic events still remains the hardest problems in neonatal care.
7,8,9

Neonatal hypoxia is one of the leading causes of neonatal mortality in
developing countries. Birth asphyxia is an important cause of static development an
neurological handicap both in term and pre term infants. In 3 to 13% of infants with
cerebral palsy(cp)have evidence of intrapartum asphyxia.
10

Cellular metabolism requires adequate oxygen supply. Brief hypoxia impairs
cerebral oxidative metabolism leading to an anaerobic glycolysis to generate ATP.
During anerobic conditions one molecule of glucose yields only 2 molecules of ATP
as opposed to producing 38 molecules of ATP during aerobic condition.Anaerobic
metabolism ensues with production of large quantities of metabolic degradation
products like lactic acid.
11,12,13,14,15
During prolonged hypoxia, cardiac output falls,
cerebral blood flow (CBF) is compromised and a combined hypoxic-ischemic insult
produces further failure of oxidative phosphorylation and ATP production, sufficient
to cause cellular damage. Lack of ATP and increase excitotoxic cellular damage leads
to an accumulation of adenosine diphosphate (ADP) and adenosine monophosphate
(AMP),which is then catabolized to adenosine, inosine and hypoxanthine.
11,12,13,14,15

4

If there is uninterrupted tissue hypoxia and there is also reperfusion injury,

hypoxanthine is oxidized to xanthine and uric acid in presence of xanthine oxidase
leading to an increase in uric acid production, which come out in blood from tissues
and excreted in urine.
11,12,13,14,15

Previous studies have demonstrated higher cord blood hypoxanthine level
concentrations in hypoxic fetuses.
16,17,18
Additional studies have indicated higher uric
acid concentration in mothers with pre eclampsia.
19,20

Though there are more and more studies for understanding mechanisms
leading to birth asphyxia, studies for early determination of tissue damages due to
birth asphyxia are still lacking.
This study was to evaluate the utility of urinary uric acid to creatinine ratio
(UA/Cr ratio) as non-invasive, easy, cheap and at the same time early biochemical
means of asphyxia diagnosis and also to find out whether Apgar score is still an
important tool for birth asphyxia diagnosis and its severity.

5

AIMS AND OBJECTIVES OF THE STUDY

1. To compare the ratio of urinary uric acid and creatinine among asphyxiated
and non-asphyxiated term neonates.
2. To evaluate the utility of urinary uric acid to creatinine ratio (UA/Cr ratio) as
non-invasive, easy, cheap and at the same time early biochemical means of
asphyxia diagnosis and also
3. To find out whether Apgar score is still an important tool for birth asphyxia
diagnosis and its severity.










6

REVIEW OF LITERATURE
HISTORICAL REVIEW
The examination of birth asphyxia from a historical perspective presents
several intriguing problems. First, of course, there is no satisfactory definition.
Clinicians, biochemists and pathologists all seem to use the phrase, but a universal
definition is lacking. Dr. Eastman of Hopkins called asphyxia "an infelicity of
etymology" since the Greek derivation of asphyxia meant "without pulse." A second
problem seems to be that, within each specialty studying asphyxia, once a definition is
established, the exceptions are enormous. For instance, to the pathologist, a defined
"asphyxic" lesion may occur without any clinical or biochemical history of asphyxia.
The term asphyxia when defined in physiology textbooks includes hypoxia plus
hypercarbia. Alternatively, biochemical evidence of asphyxia is present in tremendous
numbers of children who, in fact, are clinically completely normal.
A recent pair of published papers from the University of Pittsburgh describe
the effects of neonatal asphyxia on children. The results were based on study
conducted on 38,405 consecutive deliveries. The investigators demonstrated the
relationship between prematurity and asphyxia, and showed the positive relationship
between survival and gestational age.
21
They reconfirmed the finding that the
incidence and severity of birth asphyxia complications were not related to gestational
age. This information was not especially new. What is intriguing about these papers,
however, is the criterion used for diagnosis of asphyxia. In an age where
technological advance is a daily occurrence, and where intricate cellular physiology is
being studied in detail, these investigators used as their sole criterion for the diagnosis
7

of asphyxia, "infants who required more than one minute of positive pressure
ventilation before sustained respiration occurred." The specific etiology leading to the
absence of voluntary respiratory effort is not mentioned, nor is any reference made to
blood biochemistry.
Dr. William Little presented his paper defining a causal relationship between
abnormal parturition and central nervous system damage in 1861. Dr. Little cautioned
that the difference between apoplexy, asthenia and asphyxia was unknown but that in
asphyxia, circulatory failure was clearly a factor and an important cause of the central
nervous system (CNS) clinical pathology .
22
In fact, his talk to the Obstetric Society of
London was the culmination of a long series of studies published, in part, in Lancet
beginning several years earlier. He mentioned other authors who characterized and
commented on the immediate neonatal period but then he stated "they seem quite
unaware; that abnormal parturition besides ending in death or recovery, not
infrequently has another termination . . . in other diseases."
The expressions in vogue to describe birth asphyxia in Little's time included
"asphyxia neonatorum" and "suspended animation," a descriptive term not terribly
different from the 1980 Pittsburgh author's. He compared the appearance of these
newborn children suffering from asphyxia to adult drowning victims. Little's thesis
included an illusion to the difference between asphyxia pallida and asphyxia livida
with the former the much more ominous event. Most interesting from the historical
perspective is his observation that "it is obvious that the great majority of apparently
stillborn infants whose lives are saved by the attendant accoucheur recover unharmed
from that condition."
8

In reviewing the history of birth asphyxia, one name in perinatal medicine

which should be central is that of N. J. Eastman. Dr. Eastman's work began in the
early 1930's and was based on sound physiologic principles derived from the great
physiologists who were working in the area of respiration at that time. Dr. Eastman
defined asphyxia as "an inability of the child to breathe and apnea associated with
oxygen deficiency during labor." It was this very issue, the initiation of respiration at
birth, that stimulated Dr. Eastman's original contributions. Dr. Eastman was vitally
interested in the concept of whether hypercarbia or hypoxia was responsible for the
initiation of respiration.
23
He felt that only by understanding the normal initiation of
human respiration and the biochemistry involved at the time of initiation of
respiration, could we know the abnormalities associated with abnormal respiration,
i.e. asphyxia. His studies proceeded in a series of five articles published between 1931
and 1936.
He first studied the oxygen concentration and oxygen delivery of maternal and
fetal blood through the umbilical vein and the return of blood to the mother via the
umbilical artery, in 16 patients.
23
. His next paper used these 16 patient models as
controls for the identification of deviations from normal. He measured lactate in cord
blood of 24 patients, 7 of whom had birth asphyxia.
24
Three of these infants died and
he reported that at autopsy they had no evidence of trauma or hemorrhage. He showed
the maternal-fetal lactate relationships and indicated that this was likely a measure of
mild oxygen deficiency. He stated that the absence of hyperlactatemia demonstrated
fetal oxygen adequacy. He quoted a paper by Heinbicken, a German investigator, who
in 1929 demonstrated that cellular acidic products generated from anoxemia could
cause cellular damage. The summary of these two inquiries and their clinical
9

application is encompassed by Eastman's third paper on the subject.

25
He quoted the
Kane and Kreiselman study of 1930 showing increased carbon dioxide in the blood of
asphyxiated adult patients. Dr. Eastman then measured the carbon dioxide and pH in
normal and abnormal fetal and maternal blood. Lastly, he demonstrated that neonatal
acidosis accompanies asphyxia.
Schmidt in 1928 had published a theory of "reversal" of which Eastman
knew.
26
Schmidt stated that after prolonged oxygen deprivation and acidemia
including hypercarbia, cerebral cells, including the respiratory center, no longer could
utilize oxygen and, rather than stimulating increased respiratory activity, respiratory
depression ensued. Mathison in 1910 had demonstrated the effect of asphyxia on
reducing cardiac output. Dr. Eastman postulated from this pathophysiologic
observation that the well known ominous process of asphyxia pallida equalled
circulatory failure.
27
Eastman then concluded that high carbon dioxide or low oxygen
were not the primary initiators of respiration. He also made very clear that the goals
for resuscitation are evident. He wrote, "There seems to be only one urgent indication
in the treatment of asphyxia neonatorum, and that is to introduce oxygen into the
circulating blood of the infant." He continued "that the usual forms of stimulation
(including slapping, bathing and carbon dioxide inhalation) produce depression . . .
and may even result in irreparable damage to the brain cells."
Dr. Eastman's investigations then led him into an inquiry into the role of
anesthesia in neonatal depression and production of asphyxia.
27
In the 1930's, there
was considerable suspicion which indicated that part of the narcosis associated with
the administration of anesthetic agents was the hypoxia associated with their use, and
that the hypoxia was as responsible for the central nervous system depression as was
10

the agent itself. Dr. Eastman proceeded to look at the oxygen concentrations in both
mothers and babies and came to the conclusion that under most circumstances
depression seen following anesthesia in the neonate is, in fact, not related to oxygen
deficiency but is related to the drug used. He urged caution, however, and agreed that
the inappropriate concentrations of drugs resulted in apnea due to asphyxia, not apnea
due to anesthesia. It was this distinction that was probably the first great scientific
differentiation made in modern day perinatal medicine concerning respiratory
neonatal depression.
28,29

No review of birth asphyxia can ignore the Apgar score. Dr. Apgar, in her
original paper published in 1953, was obviously disturbed by the lack of specificity in
resuscitation.
30
She described the lack of systematic evaluation of newborns which
limited the evaluation of resuscitation methodology. She chose her criteria in part to
obviate the need for intervention during the resuscitation efforts and felt that her
criteria could be delineated without compromising care. She then correlated her score
with a variety of birthing variables including perinatal mortality and type of
anesthesia, and showed the inverse relationship of the score to the need for active
resuscitative needs. She clearly did not intend to have her score used to do more than
focus attention on the baby and its immediate needs, as well as to objectify and
systematize the process for observer communications.
Dr. Apgar's work was extended by several of her associates, notably Dr. L. S.
James. James and his coworkers converted the pathophysiology of the Apgar criteria
into human acid-base biochemical correlates.
31
Since one of the weaknesses of
historical observation in asphyxia is the lack of coordination among clinical,
11

biochemical and pathological phenomena, this less dramatic work is of critical

importance.
Although many investigators have contributed to the mystery of mechanisms
in asphyxia, Dr. William Windle deserves special mention . Primarily because of his
methodology and his gradual decision to use the subhuman primate as a model, much
of the pathophysiology of the sequelae of asphyxia is clearer. His work is most
notable because it reflects the summation of the most important correlates between
clinical state, biochemical measures and pathological findings.
32
Dr. Meyers described
the cycle of hypoxia leading to lactate dependent cellular damage which is likely
causal in brain damage. As the cells swell with secondary loss of membrane transfer
integrity, ischemia occurs, further decreasing oxygen delivery. Since, simultaneously,
cardiac muscle is being affected, resulting in reduced cardiac output, further
hypoperfusion occurs.
33
It seems fair to say that findings built upon empiric human
data such as that of Little, careful clinical observation as exemplified by Eastman, and
systemization as developed by Apgar, resulted in altered approaches to both
resuscitation and prevention.
Since the goal of observed pathophysiology should be prevention, based on
the understanding of the involved mechanisms, a variety of markers have been
examined to identify perinatal hypoxia including electronic fetal heart monitoring,
intrapartum fetal scalp blood pH, low Apgar scores, cord pH, EEG, CT and MRI
scans and Doppler flow studies. The current problem, from a historical perspective,
then becomes our inability to precisely distinguish the false positive affected from the
true positive asphyxiated or compromised fetus. Several studies have been conducted
12

to evaluate better markers that help distinguish an asphyxiated from a non-

asphyxiated neonates.
Study done by Pallab Basu,et al found that urinary uric acid and creatinine
ratio within 24 hours was higher in asphyxiated neonates than non asphyxiated ones.
34

G.Ciler Erdag,MD;A.Vitrinel,MD showed that mean uric acid and creatinine
ratio within 24hours of birth in asphyxiated neonates was more than the mean ratio for
non asphyxiated neonates.
35

Hsing-Jin Chen et al reported that urinary ratio of uric acid to creatinine may
be used as as a marker of perinatal asphyxia.In both term an preterm infants a
significantly higher urinary ratio of uric acid to creatinine was noted in the
asphyxiated group than in the non asphyxiated group.
36

Lofty M. El-Sayed et al in his study showed that urinary uric acid to creatinine
ratio in term and preterm infants was significantly higher in the asphyxia group than
in the non asphyxiated group. simultaneously he also proved that this ratio was 80%
accurate, 76.6% sensitive,83% specific;with a positive predictive value of 82.1% and
negative predictive value of 78.1% therby concluding that this test allows rapid
recognition of asphyxia, assessment of its severity and potential to predict short term
morbidity or death as well as long term outcome.
37

Akisu M et al reported that urinary uric acid and creatinine ratio was
significantly higher in the asphyxia group than in the non asphyxiated group and also
found this ratio was a good an simple screening test for early assessment of neonatal
asphyxia.
38

13

Study done by David Bader et al showed that urinary uric acid to creatinine
ratio may be used as marker of neonatal asphyxia as in term and preterm infants this
ratio was significantly higher among asphyxia group than in non asphyxiated group
thus concluding that this ratio might be used as an indicator of severity of neonatal
asphyxia.
39

C. Banupriya

et al concluded that urinary excretion rate of uric acid is higher
in asphyxiated neonates than non asphyxiated ones and has potential to act as
biochemical markers for severity evaluation and death prediction in neonatal
asphyxia.
40

Dong Wen Bin, et al displayed in his study that neonates who have suffered
asphyxia have higher urinary uric acid to creatinine ratio as compared to the non
asphyxiated ones. It might be used as an indicator for early assessment of severity of
asphyxia and post asphyxia renal injury in neonates.
41

Reem Mahmoud and Dina El Abd. Pediatric and Chemical Pathology
Departments Faculty of Medicine, Cairo University found significant correlation
between the uric acid and creatinine ratio and the severity of HIE in the asphyxiated
group (r =0.94, P < 0.001). The urinary uric acid/creatinine ratio was found to be a
good and simple screening test for the early assessment of perinatal asphyxia.
42

Naithani M Department of Biochemistry, Sri Guru Ram Rai Institute of
Medical Sciences, Deheradun, India, Dr. Ashish Kumar Simalti, MBBS, MD. Graded
Specialist in Paediatrics, Military Hospital, Agra. Noticed serum protein S-100,
brain-specific creatine kinase, neuron- specific enolase, IL6 and urinary uric acid
14

levels appear promising in identifying patients with a risk of developing hypoxic-

ischemic encephalopathy.
43

Tekgul et al.
117
found that measurement of interleukin 6 in CSF with a cut off
value of 25.9pg/ml had the highest predictive value among all other biochemical
markers of perinatal asphyxia. He suggested that measuring interleukin 6 in CSF is
superior to urinary UA/Cr ratio as a tool to diagnose PA and to predict short term
outcome of HIE but on the other hand the test is sophisticated, expensive and invasive
compared to urinary UA/Cr ratio which is simple, cheap and safe hence can be used
as a screening test in our NICUs.
Jensen et al
124
and Hasday and Grum
125
attributed the increased UA in urine
to the of hypoxia which is the cornerstone of our hypothesis in this study. Jensen et
al.
25
reported increased excretion of uric acid in premature infants with respiratory
distress syndrome suffering from hypoxia. Hasday & Grum
125
stated that urinary
UA/Cr ratio increased over night in patients with sleep associated hypoxemia.
Laing et al
126
reported that 24-hour urinary hypoxanthine/creatinine ratios
obtained after moderate or severe asphyxia were 4-8 times higher than the ratio, after
mild asphyxia.
Neonatal Perinatal asphyxia (Perinatal asphyxia)
Birth asphyxia is the most common and important cause of preventable
cerebral injury occurring in the neonatal period, but although asphyxia at birth is a
commonly made diagnosis, there is generally no accepted definition for it. The term is
used to imply an abnormal process and one that, if untreated, may cause permanent
injury. Asphyxia, at a pathophysiological level, is the simultaneous combination of
15

both hypoxia and hypoperfusion, which impairs tissue gas exchange leading to tissue
acidosis. In current clinical usage there remains variability in both the meaning and
interpretation of the term birth asphyxia. Hence when determining the incidence,
etiology and outcome of birth asphyxia there is wide variation. Many have suggested
that this term should no longer be used
44
. Since there is simultaneous occurrence of
hypoxia and ischaemia, the term hypoxic-ischaemic insult is now preferred.
Undoubtedly hypoxia-ischemia (HI) can lead to severe brain injury but a major
concern regarding the term is in those children who develop long term neurodisability
such as cerebral palsy. In these children there is an often false assumption that they
were injured during events of labour and delivery with the result that obstetricians
and midwives are targeted as the person responsible for those neurologic injuries
45
.
In resource rich countries two of every 1000 live born children develop cerebral palsy
(CP). Evidence suggests that 70-80% of these CP cases are due to prenatal factors and
that birth asphyxia plays a relatively minor role (<10%)
46
.
Of the approximately 130 million births worldwide each year, four million
infants will suffer from birth asphyxia; of these, one million will die and a similar
number will develop serious long term neurological sequelae. Ninety-eight percent of
these neonatal deaths take place in resource limited countries. This leads to a neonatal
mortality deaths rate of about 4-5 per 1000 in resource rich countries and nearly 10
times this in resource limited countries
47
.
Globally, hypoxia of the newborn (birth asphyxia) or the fetus ("fresh
stillbirth") is estimated to account for 23% of the 4 million neonatal deaths and 26%
of the 3.2 million stillbirths each year
1
.
16

Figure:1. Estimated distribution of direct causes of 4 million neonatal deaths for
the year 2000. [Adapted from Lawn 2005
1
]
There is no unanimity or consensus regarding the definition of birth asphyxia
and various workers have used different definitions making it difficult to ascertain the
incidence of asphyxia. Birth asphyxia is defined by the World Health Organization
(WHO) as the failure to initiate and sustain breathing at birth.
48
. The WHO
definition of birth asphyxia in the International Classification of Diseases (ICD-10) is
based on the Apgar scoring system. The ICD-10 definition of birth asphyxia is
dependent on the Apgar score at 1 min of age. An Apgar score at 1 min of 0-3 defines
severe birth asphyxia and an Apgar score of 4-7 defines moderate asphyxia
49
.
The NNPD 2000 used a similar definition for perinatal asphyxia and defined
moderate asphyxia as slow gasping breathing or an Apgar score of 4-6 and severe
asphyxia as no breathing or an Apgar score of 0-3 at one minute of life. The National
17

Neonatology Forum of India has defined asphyxia as gasping or ineffective

breathing or lack of breathing at one minute of life
50
.
Newer terms include birth depression, which is a descriptive term to indicate
a newborn with poor Apgars but without passing judgement on etiology. The use of
word perinatal rather than birth supports the pathological processes that may begin
many hours before birth and continue for many hours afterwards. There are numerous
causes, and the clinical manifestations vary. Infants who experience mild asphyxia
may show no neurological injury. However, severe asphyxia may be fatal in utero, or
immediately after birth, with survivors showing extensive neurological sequelae, with
or without cognitive deficits
49
.
The following terms may be used in evaluating a term infant at risk for brain
injury in the perinatal period
51
:
A. Neonatal depression
It is a general term used to describe an infant who has a prolonged transition
from an intrauterine to an extrauterine environment. These infants usually have low 1-
and 5-minute Apgar scores.
B. Neonatal encephalopathy
It is a clinical term used to describe an abnormal neurobehavioral state that
consists of a decreased level of consciousness with abnormalities in neuromotor tone.
It characteristically begins within the first postnatal day and may be associated with
seizure-like activity, hypoventilation or apnea, depressed primitive reflexes and the
18

appearance of brain stem reflexes. It does not imply a specific etiology, nor does it
imply irreversible neurologic injury.
C. Hypoxic-ischemic encephalopathy (HIE)
It is an abnormal neurobehavioral state in which the predominant pathogenic
mechanism is impaired cerebral blood flow.
D. Hypoxic-ischemic brain injury
It refers to neuropathology attributable to hypoxia and/or ischemia as
evidenced by biochemical (such as serum creatine kinase brain bound [CK-BB]),
electrophysiologic (EEG), neuroimaging (cranial ultrasonography, MRI, CT), or
postmortem abnormalities.
Incidence.
The frequency of perinatal asphyxia is approximately 1% to 1.5% of live
births in the Western Hemisphere and is inversely related to gestational age and birth
weight. It occurs in 0.5% of live born infants >36 weeks' gestation and accounts for
20% of perinatal deaths (50% if stillborns are included)
51
. A higher incidence is
noted in term infants of diabetic or toxemic mothers, infants with intrauterine growth
restriction, breech presentation, and postdates infants . Of the 26 million

births each
year in India, 4-6 per cent of neonates fail to

establish spontaneous breathing at
birth
52
. In India, 8.4% of inborn babies have a one minute Apgar score less than 7 and
1.4% suffer from HIE
2
.
19

Etiology.
In term infants, 90% of asphyxial events occur in the antepartum or
intrapartum period as a result of impaired gas exchange across the placenta that leads
to the inadequate provision of oxygen (O
2
) and removal carbon dioxide (CO
2
) and H
+

from the fetus. The remainder of these events occurs in the postpartum period and is
usually secondary to pulmonary, cardiovascular, or neurologic abnormalities
51
.
A. Factors that increase the risk of perinatal asphyxia include the following:
1. Impairment of maternal oxygenation.
2. Decreased blood flow from mother to placenta.
3. Decreased blood flow from placenta to fetus.
4. Impaired gas exchange across the placenta or at the fetal tissue level.
5. Increased fetal O
2
requirement.
B. Etiologies of perinatal hypoxia-ischemia include the following:
1. Maternal factors: hypertension (acute or chronic), infection, diabetes, hypotension,
vascular disease, drug use, and hypoxia due to pulmonary, cardiac, or neurologic
disease.
2. Placental factors: infarction, fibrosis, abruption, or hydrops.
3. Uterine rupture.
4. Umbilical cord accidents: prolapse, entanglement, true knot, compression.
5. Abnormalities of umbilical vessels.
6. Fetal factors: anemia, infection, cardiomyopathy, hydrops, severe cardiac/
circulatory insufficiency.
20

7. Neonatal factors: severe neonatal hypoxia due to cyanotic congenital heart disease,
persistent pulmonary hypertension of the newborn, cardiomyopathy, other forms of
neonatal cardiogenic and/or septic shock.
Assessment of Fetal well-being
Many different assessments attempt to predict fetal well-being during labour
and following delivery. These include observing for the passage of meconium,
electronic fetal heart rate monitoring via a cardiotocograph (CTG), Apgar score and
the assessment of fetal acid-base balance.
Meconium staining of the amniotic fluid
Heavy or thick meconium staining is considered to be a marker of more
prolonged or severe asphyxial episodes. Meconium staining is seen in approximately
15% of all labours and is present during labour in 11% of full-term pregnancies where
there is no evidence, other than the meconium, of asphyxia
53
. However, only 0.4% of
term infants with meconium-stained liquor during labour subsequently developed
cerebral palsy
54
. Richey et al
55
found no correlation between the passage of
meconium and markers of acute asphyxia (umbilical arterial pH, lactate and
hypoxanthine). This sign is poorly predictive of adverse outcome and, in one study,
more than half of infants who had early neonatal seizures (a possible indicator of
intrapartum asphyxia) showed no evidence of meconium staining. Furthermore, if
cerebral palsy is taken as the endpoint of a major asphyxial event in the perinatal
period, then 99.6% of normal birth weight infants with meconium staining had no
evidence of this condition
54
.
21

Electronic fetal monitoring (EFM)

Continuous electronic fetal monitoring is widely used despite the fact that it
has not been shown to reduce perinatal mortality or asphyxia relative to auscultation
by trained personnel but has increased the incidence of operative delivery
51
. When
used, the monitors simultaneously record FHR and uterine activity for ongoing
evaluation. Parameters of the fetal monitoring record that are evaluated include the
following
51
:
i. Baseline heart rate is normally between 110 and 160 beats per minute (bpm). The
baseline must be apparent for a minimum of 2 minutes in any 10-minute segment
and does not include episodic changes, periods of marked FHR variability or
segments of baseline that differ by more than 25 bpm. Baseline fetal bradycardia,
defined as a FHR <110 bpm may result from congenital heart block associated with
congenital heart malformation or maternal systemic lupus erythematosus. Baseline
tachycardia, defined as an FHR >160 bpm, may result from a fetal dysrhythmia,
hyperthyroidism, maternal fever, or chorioamnionitis.
ii. Beat-to-beat variability is recorded from a calculation of each RR interval. The
autonomic nervous system of a healthy, awake term fetus constantly varies the
heart rate from beat to beat by approximately 5 to 25 beats/minute. Reduced beat-
to-beat variability may result from depression of the fetal central nervous system
due to fetal immaturity, hypoxia, fetal sleep, or specific maternal medications such
as narcotics, sedatives, -blockers and intravenous magnesium sulfate.
iii. Accelerations of the FHR are reassuring, as they are during a Non stress test
(NST).
22

iv. Decelerations of the FHR may be benign or indicative of fetal compromise

depending on their characteristic shape and timing in relation to uterine
contractions.
a) Early decelerations are symmetric in shape and closely mirror uterine contractions
in time of onset, duration, and termination. They are benign and usually
accompany good beat-to-beat variability. These decelerations are more commonly
seen in active labor when the fetal head is compressed in the pelvis, resulting in a
parasympathetic effect.
b) Late decelerations are visually apparent decreases in the FHR in association with
uterine contractions. The onset, nadir, and recovery of the deceleration occur after
the beginning, peak, and end of the contraction, respectively. A fall in the heart rate
of only 10 to 20 beats/minute below baseline (even if still within the range of 110-
160) is significant. Late decelerations are the result of uteroplacental insufficiency
and possible fetal hypoxia. As the uteroplacental insufficiency/hypoxia worsens, (i)
beat-to-beat variability will be lost, (ii) decelerations will last longer, (iii) they will
begin sooner following the onset of a contraction, (iv) they will take longer to
return to baseline, and (v) the rate to which the fetal heart slows will be lower.
Repetitive late decelerations demand action.
c) Variable decelerations vary in their shape and in their timing relative to
contractions. Usually they result from fetal umbilical cord compression. Variable
decelerations are a cause for concern if they are severe (down to a rate of 60
beats/minute or lasting for 60 seconds or longer, or both), associated with poor
beat-to-beat variability, or mixed with late decelerations. Umbilical cord
23

compression secondary to a low amniotic fluid volume (oligohydramnios) may be

alleviated by amnioinfusion of saline into the uterine cavity during labor.
A normal fetal heart rate trace in labour appears to be a good indicator that
metabolic acidosis is not developing, but a severely abnormal trace with late
decelerations in the fetal heart rate is associated with significant fetal acidosis in only
about 50% of cases. A recent Cochrane review
56
showed that there was a statistically
significant reduction in neonatal seizures when EFM had been used, but no protective
effect for 1 min Apgar scores, rates of admission to neonatal units, perinatal death or
cerebral palsy.
Apgar score
Apgar scores are a method of describing the condition of an infant at birth,
originally described by Virginia Apgar
57
. Using these markers of heart rate,
respiratory efforts, tone, reflex activity and colour, a score is established at 1 min then
at 5 min intervals as necessary (maximum score 10) (Table:1)
58
. The ICD-10
definition of birth asphyxia is dependent on the Apgar score at 1 min of age. An
Apgar score at 1 min of 0-3 defines severe birth asphyxia and an Apgar score of 4-7
defines moderate asphyxia
62
. There is much debate as to whether this definition is of
clinical use. Specifically, regarding prognosis, Apgar scores in individual cases do
not appear to correlate well with outcome and hence are frequently interpreted
incorrectly from a view of long term prognosis
59
. Despite the controversy, this
definition of severe birth asphyxia (Apgar <3) appears useful in identifying a high risk
group requiring further observation of their neurological condition
60
with an
understanding that it overestimates eight-fold the scale of the problem. A low score
24

may be due to a number of factors, including drugs given to the mother during labor
and immaturity ( Table:2 )
58
.
Table:1. Apgar Evaluation of Newborn Infants
58
.
SIGN 0 1 2
Heart rate Absent Below 100 Over 100
Respiratory effort Absent Slow, irregular Good, crying
Muscle tone Limp Some flexion of
extremities
Active
motion
Response to catheter in nostril
(tested after oropharynx is clear)
No
response
Grimace Cough or
sneeze
Color Blue, pale Body pink,
extremities blue
Completely
pink







25

Table:2. Factors Affecting the Apgar Score

67
.
FALSE-POSITIVE (NO FETAL ACIDOSIS
OR HYPOXIA; LOW APGAR)
FALSE-NEGATIVE
(ACIDOSIS; NORMAL APGAR)
Immaturity Maternal acidosis
Analgesics, narcotics, sedatives High fetal catecholamine levels
Magnesium sulfate Some full-term infants
Acute cerebral trauma
Precipitous delivery
Congenital myopathy
Congenital neuropathy
Spinal cord trauma
Central nervous system anomaly
Lung anomaly (diaphragmatic hernia)
Airway obstruction (choanal atresia)
Congenital pneumonia and sepsis
Previous episodes of fetal asphyxia (recovered)
Hemorrhage-hypovolemia
26

The 1-minute Apgar score reflects the need for immediate resuscitation. The
5-minute score, and particularly the change in score between 1 and 5 minutes, is a
useful index of the effectiveness of resuscitative efforts. The 5-minute Apgar score
also has prognostic significance for neonatal survival, because survival is related
closely to the condition of the infant in the delivery room
61
. The Apgar score was not
designed to predict neurologic outcome. Indeed, the score is normal in most patients
in whom cerebral palsy subsequently develops, and the incidence of cerebral palsy is
low in infants with Apgar scores of 0-3 at 5 min (but higher than in infants with
Apgar scores of 7-10). The Apgar score and umbilical artery blood pH both predict
neonatal death. An Apgar score of 0-3 at 5 min is uncommon but is a better predictor
of neonatal death (in both term and preterm infants) than an umbilical artery pH of 7.0
or less; the presence of both variables increases the relative risk of neonatal mortality
in term and preterm infants
58
.
In an analysis of more than 150,000 infants delivered at Parkland Hospital,
Casey and associates assessed the contemporaneous significance of the 5-minute
score for predicting survival during the first 28 days of life. They found that in term
infants the risk of neonatal death was approximately 1 in 5000 for those with Apgar
scores of 7 to 10, as compared with approximately 1 in 4 for those with scores of 3 or
less (Table:3). Low 5-minute scores were comparably predictive of neonatal death in
preterm infants. They concluded that the Apgar scoring system is as relevant for the
prediction of neonatal survival today as it was almost 50 years ago
62
.
27

Table:3. Incidence of Neonatal Death in 132, 228 Singleton Infants Born at Term
(37th wk of Gestation or Later) in Relation to Apgar Scores at 5 min of Age*
62
.

5-MIN
APGAR
SCORE
NO. OF
LIVE
BIRTHS
NO. NEONATAL DEATHS
(RATE PER 1,000 BIRTHS)
RELATIVE RISK
(95% CI)
03 86 21 (244) 1, 460 (8352, 555)
46 561 5 (9) 53 (20140)
710 131, 581 22 (0.2) 1
* Infants with 5-min Apgar scores of 710 served as the reference group. CI,
confidence interval.
Table:4. Risk of death or cerebral palsy(CP) in infants >2500g with Apgar
scores 0-3 at varying times from birth [data from Nelson & Ellenberg
63
]
Age (min) Death in first year(%) CP >2500g (%)
1 3 0.7
5 8 0.7
10 18 5
15 48 9
20 59 57
Despite the methodological challenges, erroneous definitions of asphyxia by
many groups were established solely based upon low Apgar scores. The promulgation
of such definitions prompted the American College of Obstetricians and
28

Gynecologists and the American Academy of Pediatrics to issue a joint statement in

1986 on the use and misuse of the Apgar score
64
that was reaffirmed in 1996
65
.
Important caveats regarding Apgar score interpretation addressed in this statement
include the following:
Because certain elements of the Apgar score are partially dependent on the
physiological maturity of the infant, a healthy preterm infant may receive a
low score only because of immaturity.
Given that Apgar scores may be influenced by a variety of factors including,
but not limited to, fetal malformations, maternal medications, and infection, to
equate the presence of a low Apgar score solely with asphyxia or hypoxia
represents a misuse of the score.
Correlation of the Apgar score with adverse future neurological outcome
increases when the score remains 3 or less at 10, 15, and 20 minutes, but still
does not indicate the cause of future disability.
The Apgar score alone cannot establish hypoxia as the cause of cerebral palsy.
A neonate who has had an asphyxial insult proximate to delivery that is severe
enough to result in acute neurological injury should demonstrate all of the
findings listed in Table:5.
29

Table:5. Clinical Criteria Necessary to Establish That Acute Neurological Injury

in the Newborn Was Related to "Asphyxia" Proximate to Delivery
65, 66

Profound metabolic or mixed acidemia (pH<7.0) determined by an umbilical cord
arterial sample, if obtained
Apgar score of 03 for longer than 5 min
Neonatal neurological manifestationse.g., seizures, coma, or hypotonia
Multisystem organ dysfunctione.g., cardiovascular, gastrointestinal, hematological,
pulmonary, or renal system
Acidosis
Acidosis is a marker of CO2 accumulation (respiratory acidosis) and/or
metabolic acidosis as the result of anaerobic metabolism. Severe fetal or cord blood
acidosis is a marker of impaired tissue gas exchange, but there is no evidence that
acidosis per se is a cause of further tissue damage. Metabolic acidosis is an index of
anaerobic metabolism and is widely used as retrospective evidence of tissue hypoxia
and 'fetal distress'. However, umbilical arterial acidaemia at delivery, considered on
its own, is not associated with a poor outcome
67
. It is associated with a poor outcome
only when in combination with abnormal fetal heart rate patterns, depressed Apgar
scores and significant HIE
68
. Severe fetal acidosis occurs in the moribund fetus but
may also occur in the fetus who has compensated by preserving function in vital
organs. There is poor correlation between cord blood acidosis and depression of
Apgar scores. Severe fetal acidosis (pH < 7.00) occurs in 2.5 per 1000 term infants
and is often taken as representing intrapartum compromise possibly severe enough to
30

be associated with organ dysfunction, but a minority of these infants will show
neurological complications
69
. Thus there is only a very loose association between
fetal acidosis and severe fetal distress
70
.
The most useful umbilical cord blood parameter is arterial pH. It is more
representative of the fetal metabolic condition because arterial acidemia may occur
with normal venous pH. It is the gold standard assessment of utero-placental function
and fetal oxygenation/acid-base status at birth
71
.
The umbilical artery pH that defines asphyxia of a sufficient degree to cause
brain injury is unknown. The incidence of seizures and neonatal mortality is increased
in neonates with an umbilical artery pH <7.0 directly after birth. But even below this
very low pH level, the specificity is low with normal outcome reported in as many as
80% of neonates with an umbilical artery pH <7.0
72
. There is an interesting study
showing a high predictive value of arteriovenous pCO2 difference for identification of
HIE after asphyxia. A limitation of cord blood gas as a predictor is illustrated in the
newborn monkey where total asphyxia causes severe acidosis together with a decrease
in pO2 and hypercapnia, while pH and pCO
2
may remain normal during partial
asphyxia where the respiratory gas exchange to the fetus is insufficient for a longer
time diminishes gradually. This partial "non-acidotic" asphyxia still causes low pO
2

and is followed by white matter injury
73
.
Non reassuring fetal heart rate patterns, prolonged labour, meconium stained
amniotic fluid, a low 1 min Apgar score, and mild to moderate acidemia have no
predictive value for long term neurological injury without signs of encephalopathy
and seizures
74
. It is therefore essential that the entire pregnancy, labour, delivery and
31

the period well beyond birth are examined to understand fully the pathophysiological
mechanisms that are responsible for any infants brain injuries, and their long term
impact on the child
45
.
Fetal response to hypoxia-ischaemia:
The healthy fetus is able to use a variety of adaptive responses in order to help it
overcome the hypoxic-ischaemic insult. These include
83
:
reduction in body movements/ breathing movements and rapid eye movement
sleep, thus reducing energy consumption and oxygen demand;
increased oxygen extraction from the blood: the maternofetal circulation
represents a high-output oxygen supply such that almost twice the amount of
oxygen can be extracted by fetal haemoglobin before cardiac output needs to
increase. Erythropoietin concentrations are increased, stimulating fetal
erythrocyte production;
redistribution of blood supply to the central nervous system, myocardium and
adrenals at the expense of the kidneys, gastrointestinal tract, liver and muscle;
within the brain, preferential oxygenation is maintained by diverting, blood
flow to the brainstem, midbrain and cerebellum;
sympathetic response: the high catecholamine levels seen during HI increase
peripheral vascular resistance and myocardial contractility in order to maintain
perfusion, despite the fetal bradycardic response; the sympathetic stimulation
also accelerates anaerobic glycolysis, with mobilisation of liver glycogen
stores, thus maintaining the CNS, and myocardial energy substrate;
the immature CNS can more readily utilise the lactate, pyruvate and ketones
generated by anaerobic glycolysis as an alternative to glucose. Babies with
32

hyperinsulinaemia (e.g. those born to mothers with diabetes) are less able to
generate these alternative energy sources and are therefore at greater risk from
hypoxic-ischaemic injury.
Hypoxia, and to a lesser extent placental underperfusion, both hallmarks of
asphyxia, are relatively common events during labor and ones to which the fetus is
well adapted (Table:6). It is most important to realize that these are physiological
responses to perturbations in the fetal environment which are common enough during
labor to be considered 'normal'.
Table:6. Important physiological adaptations to short episodes of fetal hypoxic stress.
69

Cardiovascular responses:
Diving seal reflex
Redistribution of blood flow
Towards brain, myocardium and adrenals
Away from gut, lungs and carcass
Bradycardia
Increase in blood pressure
Regional cerebral blood flow changes:
Relative increase to brainstem
Relative decrease to cerebral cortex
Autonomic responses:
In premature animals-
Net parasympathetic response
In full-term animals-
Net sympathetic response
Cathecholamine surge:
Biochemical response:
Glycolysis
Switch from aerobic to anaerobic metabolism
33

Reflex activity
Certain diving marine mammals have the ability to redistribute their cardiac
output to vital organs and to slow their heart rate to extraordinarily low levels in order
to remain under water for up to an hour in some cases. The fetus has been shown to
have adaptive mechanisms during periods of normal hypoxic stress of labor in some
ways similar to those of the diving seal. There is a reduction of blood flow through
the descending aorta, together with reflex bradycardia
69
.
Redistribution of blood flow
Episodes of hypoxemia cause a reduction in the fetal heart rate and an increase
in blood pressure. This results in a net fall in cardiac output during the hypoxemic
event. The overall reduction in cardiac output is more than compensated by a
simultaneous redistribution of blood flow to vital organs with marked increase to the
fetal brain, heart and adrenals at the expense of less important organs like the liver,
lungs, skin and muscles (Figure:2). Blood flow to the brain is distributed towards the
phylogenetically more primitive regions, particularly the brainstem, at the expense of
the cerebral cortices, thus protecting function in the most basic and 'vital' centers
75
.
During fetal stress, high levels of circulating cortisol are produced, which may
mediate some of the vascular effects seen in the normal fetus during periods of
hypoxia. The autonomic nervous system is also closely involved with the fetal
responses to stress
69
.
34

Figure:2. Redistribution of cardiac output during HI in fetal lamb
76
.
Glycolytic activity
Glucose and oxygen are the metabolic fuels of the developing brain.
Metabolism can switch to anaerobic glycolysis during periods of hypoxia with the
production of lactic acid. This is a normal metabolic adaptation. It has been known for
three centuries that the immature animal is more resistant to asphyxia than more
mature animals of the same species. This resistance is in part due to the increased
resilience of the mature cardiovascular system, but the brain also appears to have
greater resistance and this may be due to either augmented glycolytic ability
(production of more fuel) or lower utilization of glucose by the brain
69
.
Stress vs. distress
It is clear from the above that the fetus is a beautifully adapted organism with
a number of interrelated mechanisms to protect it from the rigors of labor, both
hypoxic and ischemic. Stress is an invariable accompaniment of the birth process and
one which the fetus is well able to withstand under most circumstances. Distress may
result from a prolonged stress response and the two may merge as an imperceptible
35

continuum. It may be extremely difficult to separate fetal stress from distress using
currently available clinical methods. Fetal distress may occur as the result of a single
period of hypoxia which is too long, or periods which occur too frequently. Currently,
methods used to detect 'fetal distress' such as CTG and fetal scalp pH assessments are
really detecting degrees of fetal stress. These tests may be misinterpreted by the
obstetrician as fetal distress, but an understanding of the fetal responses to the stress
of uncompromised labor might encourage the fetus' medical attendants that s/he
requires no assistance
69
.
Clinical features after birth
Hypoxic-ischaemic encephalopathy (HIE)
Neonatal encephalopathy refers to abnormal neurological behaviour in the
neonatal period and may be caused by a wide range of conditions. If the full-term
brain has been compromised by an hypoxic-ischemic event (asphyxia) during
delivery, it is likely that the infant will show a disturbance in neurological behavior, a
state referred to as HIE. It is unclear to what extent preterm babies can manifest
similar clinical features following hypoxic-ischaemic injury compared to term babies
70
. Infants show a sequence of often transient encephalopathic behavior lasting often
for days which is dependent on the severity and duration of the asphyxial event.
Grading systems have been published to define the degree of encephalopathy. Sarnat
and Sarnat
77
introduced a grading system to describe the neurological abnormality,
which they referred to as HIE (Table:7) and which has been modified by Levene MI
78

(Table:8).
36

Table:7. Sarnat and Sarnat Stages of Hypoxic-Ischemic Encephalopathy.

77

Stage Stage 1
(Mild)
Stage 2 (Moderate) Stage 3
(Severe)
Level of consciousness Hyperalert;
irritable
Lethargic or
obtunded
Stuporous,
comatose
Neuromuscular control: Uninhibited,
overreactive
Diminished
spontaneous
movement
Diminished or
absent
spontaneous
movement
Muscle tone Normal Mild hypotonia Flaccid
Posture Mild distal
flexion
Strong distal flexion Intermittent
decerebration
Stretch reflexes Overactive Overactive,
disinhibited
Decreased or
absent
Segmental myoclonus Present or
absent
Present Absent
Complex reflexes: Normal Suppressed Absent
Suck Weak Weak or absent Absent
Moro Strong, low
threshold
Weak, incomplete
high threshold
Absent
Oculovestibular Normal Overactive Weak or absent
Tonic neck Slight Strong Absent
Autonomic function: Generalized
sympathetic
Generalized
parasympathetic
Both systems
depressed
Pupils Mydriasis Miosis Midposition,
often unequal;
poor light reflex
37

Respirations Spontaneous Spontaneous;

occasional apnea
Periodic; apnea
Heart rate Tachycardia Bradycardia Variable
Bronchial and salivary
secretions
Sparse Profuse Variable
Gastrointestinal motility Normal or
decreased
Increased diarrhea Variable
Seizures None Common focal or
multifocal (6 to 24
hours of age)
Uncommon
(excluding
decerebration)
Electroencephalographic
findings
Normal
(awake)
Early: generalized
low-voltage, slowing
(continuous delta and
theta)
Early: periodic
pattern with
isopotential
phases
Later: periodic
pattern (awake);
seizures focal or
multifocal; 1.0 to 1.5
Hz spike and wave
Later: totally
isopotential
Duration of symptoms <24 hours 2 to 14 days Hours to weeks
Outcome About 100%
normal
80% normal;
abnormal if
symptoms more than
5 to 7 days
About 50% die;
remainder with
severe sequelae


38

Table:8. A clinical grading system for hypoxic-ischaemic encephalopathy by

Levene MI.
78

Feature Mild Moderate Severe
Consciousness Irritable Lethargy Comatose
Tone Hypotonia Marked hypotonia Severe hypotonia
Seizures No Yes Prolonged
Sucking/respiration Poor suck Unable to suck Unable to sustain
Spontaneous
respiration
Mild (grade I) encephalopathy
This stage is characterised by hyperalertness, staring (decreased frequency of
blinking), normal or decreased spontaneous motor activity and a lower threshold for
all stimuli, including the easily elicited Moro reflex. Seizures are not a feature.
Moderate (grade II) encephalopathy
Seizures occur commonly. There is lethargy, hypotonia with reduced
spontaneous movements, a higher threshold for primitive reflexes, and mainly
parasympathetic responses. A consistent feature is differential tone between the upper
and lower limbs, with the arms being relatively hypotonic compared to the legs.
39

Severe (grade III) encephalopathy

These neonates are comatose, with hypotonia and no spontaneous movements.
Primitive reflexes and the suck reflex are often absent. Seizures may be frequent and
prolonged, although in the most severe cases there may be no seizure activity and an
isoelectric EEG.
Asphyxia is not the only cause of neonatal encephalopathy and alternative
causes such as hypoglycemia and meningitis must be considered and excluded before
HIE can be reliably used as a feature of postasphyxial insult (Table:9).
62
In particular,
neonatal convulsions alone with clinical interseizure normality are not a feature of
HIE, nor is the baby who shows an unchanging pattern of neurological abnormalities
in the neonatal period. It has been suggested that in the majority of cases, 'neonatal
encephalopathy' in full-term babies may not be due to intrapartum events, but may
originate in the antepartum period.
79
. The severity of HIE is the best clinical method
currently available to predict subsequent outcome following asphyxia, but it has a
number of disadvantages. Firstly, the severity of HIE can only be determined
retrospectively as the clinical neurological features of asphyxia take some time to
evolve. Secondly, other organs such as the kidneys and heart may be compromised
due to asphyxia but the fetus preserves blood flow to his brain thereby sparing
cerebral function. The lack of encephalopathy does not necessarily indicate that the
infant has not suffered from significant intrapartum asphyxia.
49

40

Table:9. Differential diagnosis of hypoxic-ischaemic encephalopathy.

49

Infective Meningitis (bacterial or viral)
Encephalitis (herpes simplex)
Traumatic brain lesion e.g. Subdural hemorrhage
Vascular Neonatal stroke
Shock secondary to acute blood loss
(antepartum/intrapartum)
Metabolic Hypoglycemia
Hypo/hypernatremia
Bilirubin encephalopathy
Inborn error of metabolism Urea cycle defects
Pyridoxine dependency
Lactate acidemias
Amino acidemias (non-ketotic
hyperglycemia)
Organic acidemias
Congenital brain malformation e.g. Neuronal migration disorder
Neuromuscular disorder e.g. Spinal muscular atrophy
Maternal drug exposure Acute or chronic
Other neurologic considerations
51

A. Increased intracranial pressure (ICP), defined as >10 mm Hg, or cerebral edema
should be regarded as an effect rather than a cause of brain damage. Cerebral
edema peaks at 36 to 72 hrs after the insult. It often reflects extensive prior
41

cerebral necrosis rather than swelling of intact cells, making this finding
consistent with a uniformly poor prognosis. Efforts to reduce ICP and cerebral
edema (high-dose phenobarbital, steroids, mannitol, and other hypertonic
solutions) do not affect outcome.
B. Seizures are described in 20% to 50% of infants with HIE, and usually start
between 6 and 24 hours after the insult. They are most often seen in Sarnat stage 2
HIE, rarely in Sarnat stage 3, and almost never in Sarnat stage 1 HIE.
1. Seizures in HIE are usually subtle, tonic, or multifocal clonic. Generalized
seizures are uncommon due to comparatively immature myelinization and
synaptogenesis of the neonatal brain.
2. Seizures may be associated with increased cerebral metabolic rate, which could
lead to further cerebral injury.
3. Seizures can compromise ventilation and oxygenation, especially in infants who
are not on mechanical ventilation. In infants on musculoskeletal blockade for
mechanical ventilation, seizures may be manifested by abrupt changes in blood
pressure, heart rate and oxygenation.
4. Seizures associated with HIE are often very difficult to control. Whether seizures
alone, in the absence of metabolic or cardiopulmonary abnormalities, lead to brain
injury is controversial.
Prognosis after HIE
In a meta-analysis of studies examining the outcome of neonates with different
HIE grades, it appears that stage I (mild HIE) doesnt confer an increased risk of
42

death or disability
80
(Table:10). Significant reduction in intelligence quotient at 8
years has been reported in children who had suffered from grade II HIE but who were
neurologically normal, compared to children with grade I HIE
81
. In a comparison of
depression of Apgar scores with HIE grading in predicting outcome, an Apgar score
of 5 or less at l0 minutes was found to be a more specific predictor of death or major
neurological sequelae than HIE grades II and III (95% versus 78%), although it was
less sensitive (57% versus 96%)
82

Table:10. Risk of death or severe handicap in remaining survivors associated
with grade of HIE.
80

Risk of death or severe handicap in remaining survivors
HIE grade
Percentage Likelihood ratio (95% CI)
Mild (I) 1.6 0.05 0.02-0.15
Moderate (II) 24 0.94 0.71-1.23
Severe (III) 78 10.71 6.71-17.1
Specific outcomes depend on the severity of the encephalopathy, the presence
or absence of seizures, EEG results, and neuroimaging findings.
1. Severity of encephalopathy can be ascertained using the Sarnat clinical stages of
HIE.
a. Stage 1 HIE: 98% to 100% of infants will have a normal neurologic outcome and <
1% mortality.
51

43

b. Stage 2 HIE: 20% to 37% die or have abnormal neurodevelopmental outcomes.

Infants who exhibit Stage 2 signs for >7 days have poorer outcomes. In one study,
half of the 42 surviving infants who had Sarnat stage 2 encephalopathy had normal
neurodevelopment at 1 year of age; approximately 10% had a normal neurologic
exam and mild developmental delay and one-third were diagnosed with CP
51
.
c. Stage 3 HIE: 50% to 89% die and all survivors have major neurodevelopmental
impairment
51
.
d. Prognosis is considered to be good if an infant does not progress to and/or remains
in stage 3 and if total duration of stage 2 is <5 days
51
e. Some neurologically normal survivors of perinatal asphyxia have problems in
school. All stage 1 HIE and 65% to 82% of stage 2 HIE children performed at
expected grade level at 8 years. In another study, children 8 to 13 years' old who
had neonatal encephalopathy plus Apgar score <4 had increased risk of problems
with mathematics (3.3 times higher), problems with reading (4.6 times higher),
epilepsy (7 times higher), minor motor problems (13 times greater), attention
deficit-hyperactivity disorder (14 times greater) compared to unaffected children.
51
2. The presence of seizures increases an infant's risk of CP 50 to 70 fold. Mortality
risk is highest for seizures that begin within 12 hours of birth (53%). Infants whose
seizure duration was 1 day had a 7% rate of CP and 11% had epilepsy on follow-
up. If seizures lasted for >3 days, the rates of CP and epilepsy were 46% and 40%
respectively.
51
3. The detection of low voltage activity, electrocerebral inactivity or burst-suppression
patterns on EEG is a better prognostic indicator of poor outcome than is the finding
of epileptiform activity. In particular, 93% of neonates with extreme burst
44

suppression activity have poor outcomes. Persistent burst suppression is associated

with an 86% to 100% risk of death or severe neurodevelopmental sequelae.
51
4. Normal findings on diffusion weighted imaging (DWI) MRI between 2 and 18 days
of age are associated with normal neuromotor outcome at 12 to 18 months.
Abnormalities of deep gray matter that are detected early have the worse motor and
cognitive outcomes. Abnormal DWI of the basal ganglia noted within 10 days of a
hypoxic-ischemic insult was associated with a 93% risk of abnormal
neurodevelopmental outcome at 9 months to 5 years.
51
Multiorgan dysfunction (MOD)
The fetus copes with an asphyxial event by a number of protective reflexes to
preserve function to vital organs. Less well-perfused tissues may be particularly
vulnerable to hypoxic-ischemic injury. In a term infant with perinatal asphyxia renal,
neurologic, cardiac and lung dysfunction occurs in 50%, 28%, 25% and 23% cases
respectively.
4
The kidney appears to be most vulnerable, followed by the brain and
then the heart. Gastrointestinal complications of asphyxia are uncommon (Table:11).
45

Table:11. Multiorgan Systemic Effects of Asphyxia.

83

SYSTEM EFFECT
Central nervous
system
Hypoxic-ischemic encephalopathy, infarction, intracranial
hemorrhage, seizures, cerebral edema, hypotonia, hypertonia
Cardiovascular Myocardial ischemia, poor contractility, cardiac stun, tricuspid
insufficiency, hypotension
Pulmonary Pulmonary hypertension, pulmonary hemorrhage, respiratory
distress syndrome
Renal Acute tubular or cortical necrosis
Adrenal Adrenal hemorrhage
Gastrointestinal Perforation, ulceration with hemorrhage, necrosis
Metabolic Inappropriate secretion of antidiuretic hormone, hyponatremia,
hypoglycemia, hypocalcemia, myoglobinuria
Integument Subcutaneous fat necrosis
Hematology Disseminated intravascular coagulation
Recently, reports have been published of babies with HIE who later developed
cerebral palsy, but who have not shown MOD.
84
Lungs
During intrapartum asphyxia, the fetus commonly passes meconium and
gasping may occur due to brainstem compromise. The gasp causes meconium to be
aspirated deep into the bronchial tree and this may cause a chemical pneumonitis with
46

severe pulmonary hypertension and a high risk of air leak. Those infants who are
pharmacologically paralyzed in order to facilitate mechanical ventilation for
meconium aspiration syndrome will not show clinical signs of encephalopathy and
coincidental cerebral injury may not be recognized. These infants should have
continuous EEG monitoring to assess cerebral function.
69
Cardiovascular system
Blood flow to the myocardium is preserved during asphyxial episodes but
cardiac compromise is a relatively common complication of hypoxic-ischemic injury.
Myocardial dysfunction detected by Doppler ultrasound studies has been reported in
28-40% of asphyxiated infants.
4
Recognized complications include cardiogenic shock
and hypotension, functional tricuspid incompetence secondary to acute cardiac
dilation, arrhythmias and myocardial ischemia which may be diagnosed from the
electrocardiogram. The electrocardiography may show ST depression in the
midprecordium and T-wave inversion in the left precordium. Echocardiographic
findings include decreased left ventricular contractility, especially of posterior wall;
elevated ventricular end-diastolic pressures; tricuspid insufficiency and pulmonary
hypertension due to poor ventricular function. In severely asphyxiated infants,
dysfunction more commonly affects the right ventricle. A fixed HR may raise
suspicion of clinical brain death .
51
Renal impairment
The kidney is the most common organ to be affected in perinatal asphyxia.
51

The proximal tubule of the kidney is especially affected by decreased perfusion.
Acute tubular necrosis and oliguria occurs commonly following episodes of asphyxia.
47

This usually recovers with supportive treatment alone. The incidence of renal
impairment (oliguria) after birth asphyxia occurs in 23-55% of babies and acute renal
failure was reported in 19% of asphyxiated infants.
85
Acute retention of urine is also a
relatively common complication following birth asphyxia and usually indicates very
severe compromise, often associated with severe cerebral injury. Renal failure
following asphyxia has also been reported to be due to myoglobinuria.
61
Gastrointestinal tract
Necrotizing enterocolitis is associated with hypoxic-ischemic events but in
mature infants this is rarely seen in conjunction with HIE.
69
Metabolic disorders
One of the commonest metabolic complications of birth asphyxia is
inappropriate antidiuretic hormone secretion with concentrated urine, dilute plasma
and hyponatremia. Transient hyperammonemia has been reported with asphyxia but
the precise cause of this metabolic compromise is not known.
69

Hematological disorders
Disseminated intravascular coagulation (DIC) is a well-recognized
complication of birth asphyxia and usually presents with excessive bleeding from
puncture sites together with petechial hemorrhages. Secondary complications such as
intracranial hemorrhages may occur as the result of the DIC.
69

The combined criteria for MOD are based on biochemical and clinical
measurements and differ somewhat between different studies (4, 86, 87). Criteria used
by Shah et al
86
are listed in Table:12.
48

Table:12. Criteria for organ dysfunction in newborn infants with perinatal

asphyxia used by Shah et al 2004.
86

Renal: anuria or oliguria (< 1ml/kg/h) for 24h or more, and a serum creatinine
concentration > 100mmol/L; or anuria/oliguria for > 36h; or any serum creatinine >
125mmol/L; or serial serum creatinine values that increase postnatally
Cardiovascular: hypotension demanding treatment with an inotrope drug for more
than 24h to maintain blood pressure within the normal range, or electrocardiographic
evidence of transient
myocardial ischemia
Pulmonary: need for ventilator support with oxygen requirement > 40% for at least
the first four hours after birth
Hepatic: AST > 100U/L or ALT > 100U/L at any time during the first week after
birth
The gamut of organ involvement in perinatal asphyxia varies among series,
depending in part upon the definitions used for asphyxia and organ dysfunction. In a
retrospective study of 130 term infants with asphyxia, the proportion of those with
organ dysfunction was: renal 70%, cardiovascular 62%, pulmonary 86%, hepatic
85%.
86
These proportions are similar across different studies.
86,87
In another series of
152 asphyxiated term infants followed prospectively, neurologic and systemic
complications occurred in 43% and 57%, respectively. Organ dysfunction included
respiratory abnormalities 39%, infection 17%, gastrointestinal intolerance 15%.
49

Infants were considered to have asphyxia if they had fetal distress, were depressed at
birth, and exhibited a metabolic acidosis.
51
.
General aspects of Pathophysiology of hypoxia-ischemia (HI)
Cell damage
When a cell is exposed to HI the outcome depends of the degree and duration
of the insult. If the insult is brief the cellular injury may be reversible. However, if the
HI is severe enough the cell will be irreversibly damaged and die. The two main,
known routes leading to cell death are necrosis and apoptosis. The etiological and
molecular mechanisms leading to one or the other are different in many aspects while
others are present in both. Briefly necrosis is seen after loss of blood supply to the cell
but also if the cell is exposed to different kinds of toxins. Apoptosis is seen both under
normal and pathological conditions.
88
The general main actions in the
pathophysiological mechanisms of cell death are presented in Figures:3 and 4.

Figure:3. The principal cellular and biochemical sites of damage in cell injury.
Mitochondrial damage may lead to reversible injury and death by necrosis or
apoptosis. [Adapted from Robbins Basic Pathology (Kumar et al 2008)
88
.]
50

Figure:4. Schematic summary of mechanisms involved in hypoxia-ischemia induced
cellular injury. [Adapted from Robbins Basic Pathology (Kumar et al 2008)
88
.]
Membrane injury
The mechanism of how the different cellular membranes are damaged during
HI is multi factorial and not exclusively induced by the free radicals. Calcium influx
activates phospholipases that will have negative impact on the membrane
phospholipids and proteases that will damage the cytoskeleton. As the membranes
lose their integrity there, is a great risk that the damage will become irreversible with
massive calcium influx and profound leakage of intracellular enzymes into the
peripheral circulation (Figure:5).

51

Figure:5. Mechanisms of membrane damage in cell injury. [Adapted from
Robbins Basic Pathology (Kumar et al 2008)
88
.]
Specific aspects of Pathophysiology of perinatal asphyxia
Being born is stressful, particularly if it is by vaginal delivery. During normal
labour there is transient fetal hypoxia during each uterine contraction
89
which results
in the fetus becoming more acidaemic as the labour progresses . These changes have
been followed by serial fetal scalp samples during the first and second stages of
labour. Hormones associated with a stress response and biochemical markers of
asphyxia (Table:13) are released by the fetus. In general, the greater the stress and
trauma of the labour the higher the level of hormones released. Yet despite enduring
this process for several hours, most newborn infants are pink, vigorous and breathing
regularly by 1-2 minutes of age
90
. Unfortunately, not all babies make the transition to
52

an extra uterine environment without help. In these babies the action that is taken in
the next few minutes can mean the difference between death, survival with cerebral
palsy or neurologically intact survival.
Table:13. Markers of hypoxia/stress in the neonate as a result of normal labour.
90

Catecholamines
Arginine vasopressin
Renin
Angiotensin
Endothelin I
Cortisol
-Thyroid activity
-PaO2
Hypoxanthine
Endorphins
Plasma CK-BB
Causes of delayed onset of regular respiration
A frequent misconception is that delayed onset of respiration at birth is always
the result of intrapartum asphyxia, but many additional factors can delay the onset of
respiration after delivery . Several of these may be present in a single baby yet each
one needs to be recognized as quickly as possible and properly treated. In general,
53

asphyxia and the conditions listed in Table:14 either prevent the onset of
spontaneous respiration or cause a serious reduction in the baby's respiratory efforts.
Table:14. Factors other than asphyxia that may delay the onset of respiration
after delivery.
90

Central nervous system injury or abnormality present prior to labour
Drugs depressing the central nervous system
Maternal hypocapnia
Trauma, especially to the central nervous system
Prematurity, in particular surfactant-deficient, stiff lungs
Sepsis, especially group B streptococci
Muscle weakness due to prematurity or primary muscle disease
Anemia, hypovolemia
Congenital malformations
- Obstructing the airway or preventing lung expansion
- Neurological, impairing respiratory control
Pre-existing brain disease
Case reports in the past established that babies who had suffered severe insult
some time before labour could show fetal distress, develop neurological signs
including encephalopathy in the neonatal period, and end up with cerebral palsy
90
. A
study from Oxford
91
showed that babies who died following a labour charcterised by
marked CTG abnormalities had pathological changes in their brain that were old and
54

must have antedated labour. Thus brain damage developing before labour can cause
fetal distress in labour, a low Apgar score and neonatal death. A case control study in
Western Australia found no evidence of intrapartum hypoxic ischaemia in over 70%
of babies with early neonatal encephalopathy
92
. Rarely, congenital malformations of
the brain or congenital myopathies may also result in a baby being born with poor
Apgar scores not due to perinatal asphyxia, and some babies with diagnoses such as
Smith-Lemli-Opitz syndrome, other inborn errors of metabolism or chromosomal
malformations can develop rarely encephalopathy
93
.
Depression of the respiratory centre
Pharmacological
Almost all the drugs used as analgesics, sedatives or general anaesthetics
during labour can cross the placenta and, in theory, depress the neonatal respiratory
centre. However, respiratory depression from drugs is likely to be important only in
premature babies or those who have also suffered some degree of intrapartum
asphyxia. A drug-exposed full-term baby with an [H+] less than 55nmol/l (pH >7.25)
will probably establish regular respiration unless the level of drug in the plasma is
very high
90
.
Hypocapnia
The maternal PaCO
2
may be reduced in women who are using one of the
breathing techniques associated with 'natural' childbirth or an inhalational analgesic
such as Entonox. The hyperventilation may be involuntary during a general
anaesthetic if there is exuberant bag squeezing by the anaesthetist. The fetal PaCO
2
is
in equilibrium with that of the mother, and a fetus born with a PaCO
2
less than 4kPa
55

(30 mmHg) lacks the carbon dioxide drive to ventilation and may remain apnoeic
until his PaCO
2
rises sufficient to stimulate the respiratory centre
94
. Maternal
hypocapnia may also reduce placental blood flow and thereby cause fetal hypoxia and
acidaemia
90
.
Trauma
In babies born in poor condition at birth after a traumatic forceps or breech
extraction it is difficult to separate the effects of trauma from the fetal asphyxia,
which often coexists. Trauma alone is now very rare with improvements in obstetric
practices but may, for example, cause subdural haemorrhage in a baby who is in good
condition at birth but who deteriorates during the first 12-24 hours as the haematoma
increases in volume. It is important to remember that subdural haemorrhage may
occur after a spontaneous vaginal delivery
90
.
Endorphin levels are higher in the cord blood of infants exposed to the
physical stresses of vaginal delivery and, as these substances may depress neonatal
ventilation
90
, it follows that trauma can indirectly depress the central nervous system.
Anaemia
The infant who is severely anaemic may be in high-output heart failure. He
lacks haemoglobin to deliver oxygen to the tissues and this will make him more
susceptible to asphyxia. Without haemoglobin he lacks one of the body's major
buffers and may therefore be more acidaemic
95
.
56

As a result he may be in very poor condition at delivery and may not only
breathe inadequately but respond poorly to resuscitation. The two most likely causes
of severe anaemia at birth are Rhesus incompatibility and fetal haemorrhage.
Sepsis
Babies suffering from severe intrapartum infection, both preterm an at term,
classically due to Listeria or group B streptococci can be born with very poor Apgar
scores, although they are not asphyxiated
90
.
It is increasingly recognized that perinatal asphyxia is a relatively rare cause of
permanent CNS damage
96
. Nevertheless intrapartum asphyxia is the cause of some
cases of perinatally acquired brain damage. If a baby does not breathe after delivery,
his PaO2, falls immediately to close to zero and he rapidly becomes acidotic, that is,
he develops the biochemical stigmata of asphyxia , which can also cause brain
damage or aggravate pre-existing CNS injury
90
.
Acute asphyxia
The animal model for acute neonatal asphyxia
97
has been used to explain the
physiological changes in the infant who is not breathing immediately after delivery,
and provides the theoretical basis for the management of his resuscitation.
Acute postnatal asphyxia is induced in newborn animals by delivering them in
good condition by caesarean section and then preventing them from breathing by
immediately sealing their heads in a bag of saline. A very characteristic sequence of
events then takes place (Figure:6). After a few shallow breaths which, owing to the
nature of the experiment, cannot result in any gas exchange, the animal stops
57

'breathing'. This early period of apnea, so-called primary apnea, may last for up to
10 minutes. However, after 1-2 minutes in primary apnea the animal usually starts to
gasp: the gasps occur with increasing frequency and vigour but then decreasing until
the animal literally reaches the last gasp. The heart rate falls rapidly after the onset of
asphyxia, plateaus or may rise slightly in primary apnoea and early in the phase of
gasping, then begins to slow. Cardiac activity continues for 10 minutes or more after
the last gasp. The period between the last gasp and cardiac arrest is known as
secondary or terminal apnoea. The changes In blood pressure parallel those in heart
rate. A severe mixed acidaemia develops
90
.

Figure:6. Physiological changes during asphyxia and resuscitation of newborn
animal.
98

58

The neonatal primate is capable of surviving at least 20 minutes of complete

oxygen deprivation, but in the latter part of this period brain damage is occurring.
Survival is due to the existence of large stores of glycogen in the brain, liver and
myocardium, which can produce energy by anaerobic glycolysis during asphyxia and
also to the ability of neonatal brain tissues to metabolise fuels such as lactate and
ketones. Reduction in the stores of glycogen for any reason, such as growth
retardation or preceding partial asphyxia, will reduce the fetus's ability to withstand an
acute asphyxial insult. Brain damage has been described in monkeys sacrificed
towards the end of the phase of gasping, but as many human neonates clinically
assessed to be in terminal apnoea when resuscitated survive without neurological
sequelae, it seems probable that brain damage following acute asphyxia is not
inevitable unless it is severe, prolonged, or was superimposed on preceding chronic
partial asphyxia
90
.
In infants resuscitated from terminal apnoea the time from the onset of
artificial ventilation to either the first gasp or regular respiration is proportional to the
severity of the asphyxia before ventilation was started. If artificial ventilation was
started before the pH was depressed too far, the infant may be expected to gasp (a
Head's paradoxical reflex) and start regular respiration after 3-4 minutes of
intermittent positive pressure ventilation whereas if resuscitation was started well into
terminal apnoea when the [H+] was probably greater than 150nmol/l (pH <6.8),
gasping may be delayed for 20 minutes and regular respiration for over half an hour.
Therefore, those infants who have not started to breathe spontaneously 4 -5 minutes
after starting IPPV should, in the absence of other causes of neonatal respiratory
depression, be assumed to have a very low pH
90
.
59

Chronic in-utero 'prolonged partial' asphyxia

Episodes of acute total asphyxia creating sudden total fetal anoxia as described
above are relatively rare in clinical practice. More common are events that lead to the
gradual development of fetal hypoxia, acidaemia and chronic partial asphyxia. This
can occur before or during labour. For example, some hours or even days before
delivery a fetus may suffer a hypoxic/ asphyxial insult that is not severe enough to kill
the fetus but that can cause neurological damage
99
. By the time the mother of such a
neonate goes into labour, the neonate may have made a complete biochemical
recovery and have normal blood gases
100
.As the neonate has not suffered intrapartum
asphyxia the neonate may well show no signs of respiratory depression at birth, have
a good Apgar score and establish regular breathing without any apparent problems
90
.
In clinical practice this 'chronic partial' HI can occur if labour is augmented or
if there are additional problems, such as maternal supine hypotension. Pathological
causes of chronic partial hypoxic ischaemia in clinical practice include excessive use
of oxytocic drugs, the effect of labour on a growth-retarded fetus who already has
reduced umbilical blood flow, which falls even further during the normal uterine
contractions of labour, or recurrent episodes of umbilical cord occlusion caused by
entanglement around a fetal part or compression of the cord between the presenting
part and the pelvis
90
.
During such episodes the fetal blood pressure is normal or high to start with,
and although the heart rate is commonly sustained there may be bradycardia; the
cardiac output is diverted primarily to the placenta, adrenals, brain and
myocardium
101
. The fetal PO
2
and pH fall, and energy is produced by anaerobic
60

metabolism of glycogen and glucose to lactate. Because the PCO

2
also rises, a
combined metabolic and respiratory acidaemia develops. These changes may resolve
rapidly if normal uteroplacental function is restored and the asphyxia is transient or
treated
102
. However, if the heart rate and blood pressure fall the vital organs will
eventually become ischaemic
101
and brain damage occurs. The pattern of damage seen
after chronic partial intrauterine hypoxic ischaemia is that of global neuronal loss, (so-
called selective neuronal necrosis) and the brain also characteristically shows damage
in the watershed areas between the arteries supplying the cerebral cortex, with
parasagittal cerebral injury
103
.
If episodes of partial asphyxia have been short-lived the fetus is unlikely to be
seriously damaged; if delivered promptly, although his respiration may be depressed
immediately after delivery and he may be acidaemic with a poor Apgar score, he
usually responds quickly to resuscitation and is unlikely to suffer sequelae
90
.
Finally, it is probably quite common for a fetus to recover from, or be
resuscitated from, in-utero asphyxia, and even for his acid-base status to recover in
the presence of persisting hypoxia. In such cases the fetus with a reasonable pH may
make a satisfactory transition to extra uterine life (i.e. have a reasonable Apgar score),
yet have suffered in-utero asphyxia with damage to his central nervous system, which
will manifest as HIE in the neonatal period. Similar in-utero recovery can also occur
after a single, acute, brain-damaging asphyxial insult
90
.
This potential for 'in-utero resuscitation' is yet another reason for the poor
association between Apgar scores, cord blood gases and subsequent neurological
61

disorders, and also explains why some babies who develop severe HIE cause few
resuscitation problems in the labour ward
104
.
The fact that prenatal asphyxia can evolve in these many different ways in the
hours and days before and after delivery has important clinical and medico legal
implications, of which the three most important are
90
.
1) most babies who have signs of fetal distress, a low Apgar score or acidaemia on
cord blood gas analysis are normal in the neonatal period and on follow-up.
2) intrauterine problems days or weeks before labour can cause severe long-term
neurological defects, yet the baby may show few if any neurological abnormalities
in the neonatal period.
3) in the absence of clinically apparent HIE in the neonatal period it is highly unlikely
that intrapartum events are responsible for neurological sequelae.
Observed patterns of brain injury following hypoxia-ischaemia
Cerebral oedema
Within 24-48 hours gross swelling of the cerebral tissue may occur, with
marked flattening and widening of the gyri plus obliteration of the sulci, seen on
imaging or at post mortem. It arises through two mechanisms: cytotoxic, when
membrane pump failure leads to intracellular fluid accumulation, and vasogenic,
when the impaired blood-brain barrier permits capillary leak and interstitial fluid
accumulation
90
.
Selective neuronal necrosis
This is the most commonly observed pathology following hypoxia ischaemia
in term infants, affecting neurons in a scattered fashion and often widely distributed
62

throughout the grey matter. The cerebral cortex layers III and IV and the hippocampus
appear particularly vulnerable. This may reflect differing metabolic rates of the
various cortical structures
90
.
Basal ganglia and brainstem
In animal models this pattern of injury is seen following acute total asphyxia
rather than chronic partial asphyxia. Basal ganglion injury is thought to be responsible
for the dyskinetic type of cerebral palsy seen in survivors of hypoxia-ischaemia, and
abnormal signal intensity in the basal ganglia is a common finding on MRI. Within
the first weeks, abnormal capillary proliferation and microcalcification can be seen on
histology. Abnormalities detected at this stage by ultrasound or CT are thought to
represent these pathological processes. If the infant survives for several months, an
abnormal myelination pattern occurs that is detectable on MRI. Haemorrhage and
haemorrhagic infarction affecting the thalami following hypoxia-ischaemia are also
well recognised phenomena
90
.
Parasagittal injury
This is an ischaemic injury affecting the cerebral cortex and subcortical white
matter in vascular watersheds between the anterior, middle and posterior cerebral
arteries, giving rise to a parasagittal distribution, and is often symmetrical
90
.
White matter injury
Ischaemic insults in preterm infants produce periventricular leukomalacia.
Periventricular glia are vulnerable to ischaemia in preterm infants. When ischaemic
white matter injury occurs at term, it usually results in subcortical leukomalacia. The
63

survivors of the most severe insults usually show a mixed pattern of injury referred to
as multicystic leukoencephalopathy
90
.
Focal cerebral infarction
Infarction of a major cerebral artery most commonly the left middle cerebral
artery, has in the past been reported in association with asphyxia, but it is now
realised that this lesion occurs much more commonly in infants with no evidence of
intrapartum asphyxia (67%)
103
.
Cardiovascular response in asphyxia
Severe total or partial asphyxia causes a decreased ventricular contractility and
diminished cardiac output . This contractile dysfunction of the heart is seen together
with biochemical and radiographic evidence of TMI
105-107
. In the myocardium,
Adenosine - 5- triphosphate (ATP) depletion is the main event leading to injury
during and after ischemia.
The clinical symptoms of TMI are heterogenic, ranging from tachycardia,
murmurs (from tricuspid valve insufficiency), and congestive heart failure to
cardiogenic shock in the severe cases
108
. Due to the insufficient cardiac function,
hypotension is frequently seen after asphyxia
109
.
Experimental data suggests that the immature heart recovers in functionality
better than the adult heart after short periods of ischemia
110
.The neonatal heart relies
to a greater extent on its own glycogen storage by converting it to glucose through
glycogenolysis
111
. In the myocardium, calcium activate the proteins thus leading to
contraction. The calcium is mainly released from the sarcoplasmic reticulum in the
64

mature heart . This is not seen in newborn rats and it seems likely that newborns are
more dependent on extracellular calcium compared to adults
112
. Thus, for the
immature heart, specific and normal functions such as substantial glycogen stores,
improved anaerobic metabolism
98
, better calcium exchange during ischemia and
increased amino acid substrate utilization
110
make it less sensitive to ischemia
compared to the adult heart.
Histological findings relating to the heart reported in neonates after asphyxia
include congestion, myocardial and subendocardial hemorrhage or necrosis,
cardiomyopathy and infarction of the endocardial muscles (including necrosis of the
papillary muscle)
113
.
Renal dysfunction
Kidney involvement is common after perinatal asphyxia, as a consequence of
the redistribution defence mechanism described in. Clinically, oliguria, increased
creatinine levels and electrolyte disturbances are seen. The clinical symptoms are
usually reversible
114
.
Liver
Liver cell injury commonly occurs after HI, hypotension and poor perfusion
115

e.g. after perinatal asphyxia
86,87
. The terms shock liver syndrome and ischemic or
hypoxic hepatitis are all used for the same condition. It is defined as an early, sharp
and transient increase in aminotransferases (AST and ALT) and LDH plasma activity
seen after an acute cardiac or circulatory failure in the absence of viral hepatitis
116
.
The time course of the enzyme activity pattern in hypoxic hepatitis is similar between
patients, with a slightly increased serum AST and/or serum ALT close to the trigging
65

event, followed by a peak concentration of aminotransferases and LDH in serum

within 24 to 72h after the insult
6-8
. After the peak, aminotransferase levels return to
near normal within ten days
116
. The prognosis of hypoxic hepatitis itself is good and it
rarely progresses into complete hepatic failure
113
.
Perinatal asphyxia is a devastating clinical condition because of its potential
for causingpermanent damage, even death of the fetus or newborn infant. The value of
present biochemical markers for diagnosing asphyxia is inadequate
and controversial.
117
In humans, UA is the end product of purine metabolism
118
. It is
derived from either the increased turnover of purines or from the increased catabolism
of tissue nucleic acids. Two isoenzymes, xan thine oxidase and dehydrogenase, de
grade the purines, xanthine and hypoxanthine, to UA. Xanthine dehy drogenase
produces UA and reduced nicotinamide adenine dinucleotide, and xanthine oxidase
produces UA and su peroxide. Under certain conditions such as hypoxia or ischemia,
there is increased conversion of the dehydrogenase form to the oxidized form. UA is
a poorly soluble acid that requires continuous ex cretion by the kidneys to avoid toxic
accumulation. Because of its poor solubility, alterations in its production or excretion
can produce high serum levels.
119,120

The renal elimination of uric acid involves four components: glomerular
filtration, reabsorption, tubular secretion and reabsorption beyond secretory sites.
Increased excretion of uric acid may be caused by metabolic changes, reflecting
cellular hypoxia or by renal changes. During reoxygenation after asphyxia or during
reperfusion after ischemia, hypoxanthine which accumulated in both circulating blood
and tissues is oxidized to uric acid
121
Because urinary creatinine can be used as the
reference substrate in a spot urine sample, an increased UA/Cr ratio (as a sign of
66

increased ATP degradation) may be a valuable indicator of the severity of tissue

hypoxia in patients with intact renal functions
122

Chen et al(1999). who suggested that urinary ratio of UA to creatinine was
significantly higher both full term and preterm infants with perinatal asphyxia than in
those without PA. He proved that when the urinary ratio of UA /Cr was greater than
0.95, PA was identified with sensitivity of 80% and a specificity of 71% in term
infants and in preterms a cut off value of UA / Cr of 2.9 had a sensitivity of 71% and
a specificity of 70% in daignosing perinatal asphyxia.
36

Banupriya et al (2008) reported that urinary excretion rate of uric acid in
addition to malondialdehyde and proteins are significantly higher in PA and correlates
with APGAR and the severity of HIE. Moreover he stated that a cut off value of 2.34
Uric Acid / mg of creatinine canpredict impending death in PA. This coincided with
our results in which two hypoxic newborns who died had U A / Cr ratio of 4.68, and
4.94. He concluded in parallel to our conclusion that urinary UA/Cr ratio has potential
to act as biochemical marker for severity evaluation and death predicition.
40

Mehes et al
123
who reported elevated urinary UA/ CR Ratio in full term infants
with PA and that the ratio correlates with the severity of HIE. They concluded that
UA/ Cr ratio is a good and simple screening test for the early assessment of perinatal
asphyxia.
Study done by Pallab Basu,et al(2008) found that urinary uric acid and
creatinine ratio within 24 hours was higher in asphyxiated neonates than non
asphyxiated ones.
34

67

G.Ciler Erdag,MD;A.Vitrinel,MD) showed that mean uric acid and creatinine

ratio within 24hours of birth in asphyxiated neonates was more than the mean ratio for
non asphyxiated neonates.
35

Lofty M. El-Sayed et al in his study showed that urinary uric acid to creatinine
ratio in term and preterm infants was significantly higher in the asphyxia group than
in the non asphyxiated group. simultaneously he also proved that this ratio was 80%
accurate, 76.6% sensitive,83% specific;with a positive predictive value of 82.1% and
negative predictive value of 78.1% therby concluding that this test allows rapid
recognition of asphyxia, assessment of its severity and potential to predict short term
morbidity or death as well as long term outcome.
37

Akisu M et al(2007) reported that urinary uric acid and creatinine ratio was
significantly higher in the asphyxia group than in the non asphyxiated group and also
found this ratio was a good an simple screening test for early assessment of neonatal
asphyxia.
38

Study done by David Bader(1995) et al showed that urinary uric acid to
creatinine ratio may be used as marker of neonatal asphyxia as in term and preterm
infants this ratio was significantly higher among asphyxia group than in non
asphyxiated group thus concluding that this ratio might be used as an indicator of
severity of neonatal asphyxia.
39

Dong Wen Bin, et al(2002) displayed in his study that neonates who have
suffered asphyxia have higher urinary uric acid to creatinine ratio as compared to the
non asphyxiated ones. It might be used as an indicator for early assessment of severity
of asphyxia and post asphyxia renal injury in neonates.
41

68

Reem Mahmoud and Dina El Abd(2010). Pediatric and Chemical Pathology

Departments Faculty of Medicine, Cairo University found significant correlation
between the uric acid and creatinine ratio and the severity of HIE in the asphyxiated
group (r =0.94, P < 0.001). The urinary uric acid/creatinine ratio was found to be a
good and simple screening test for the early assessment of perinatal asphyxia.
42

Naithani M Department of Biochemistry,(2011) Sri Guru Ram Rai Institute of
Medical Sciences, Deheradun, India, Dr. Ashish Kumar Simalti, MBBS, MD. Graded
Specialist in Paediatrics, Military Hospital, Agra. Noticed serum protein S-100,
brain-specific creatine kinase, neuron- specific enolase, IL6 and urinary uric acid
levels appear promising in identifying patients with a risk of developing hypoxic-
ischemic encephalopathy.
43

Tekgul et al.
117
found that measurement of interleukin 6 in CSF with a cut off
value of 25.9pg/ml had the highest predictive value among all other biochemical
markers of perinatal asphyxia. He suggested that measuring interleukin 6 in CSF is
superior to urinary UA/Cr ratio as a tool to diagnose PA and to predict short term
outcome of HIE but on the other hand the test is sophisticated, expensive and
invasive compared to urinary UA/Cr ratio which is simple, cheap and safe hence can
be used as a screening test in our NICUs.
Jensen et al
124
and Hasday and Grum
125
attributed the increased UA in urine to
the of hypoxia which is the cornerstone of our hypothesis in this study. Jensen et
al.
124
reported increased excretion of uric acid in premature infants with respiratory
distress syndrome suffering from hypoxia. Hasday & Grum
125
stated that urinary
UA/Cr ratio increased over night in patients with sleep associated hypoxemia.
69

Laing et al
126
. Reported that 24-hour urinary hypoxanthine/creatinine ratios
obtained after moderate or severe asphyxia were 4-8 times higher than the ratio, after
mild asphyxia. Because of the large amounts of oxygen radicals that are produced in
the reoxygenation period, it is expected that high levels of uric acid are produced and
excreted in the early part of this period. In animal experiments, uric acid production
reached its peak around 10 hours after re oxygenation. Increased excretion of uric acid
can be measured in the early urine samples after delivery, but the time at which the
assay is carried out seems to be critical and therefore the assay should be performed
on the earliest void samples after the asphyxiating event.
11
The urinary UA/Cr ratio allows rapid recognition of asphyxia and assessment
of its severity and the potential for short term morbidity or death. While numerous
indicators for asphyxia are recognized, no single indicator has been found to be
predictive of subsequent morbidity. The Apgar scores have historically been used to
define asphyxia and attempt outcome Prognostication
126
. Although several
biochemical indicators of asphyxia such as lactate, hypoxanthine, brain isoenzyme of
creatinine phosphokinase, neuron specific enolase, excitatoryamino acids,
erythropoietin and vasopressin, have been reported, they are most useful as research
goals and are not available in most clinical services.
127

However, we found the UA/Cr ratio to be a good, simple screening test for the
early assessment of perinatal asphyxia, Furthermore, there is a correlation between the
UA/Cr ratio and the severity of the encephalopathy, indicating the degree of injury at
an early stage when other quantitative methods frequently cannot be carried out.
However, this ratio does not provide further prognostic information that must be
obtained by other methods.
70

UA/Cr ratio obtained in an early void urine sample is a simple, quick,

inexpensive and reliable method for diagnosing perinatal asphyxia in a neonatal ICU
within 24 hours after birth and it correlates with the severity of HIE. However this
marker should be examined for its reliability in a fresh clinical sample in NICU before
it can be applied to the routine clinical of infants with perinatal asphyxia.








71

MATERIALS AND METHODS

SOURCE OF DATA
The study was a prospective study conducted on asphyxiated and non-
asphyxiated term neonates recruited from Neonatal Intensive Care Unit (NICU) and
Post natal wards of Sri Adichuchanagiri Institute of Medical Sciences, B.G.Nagara
from December 2009 to December 2010. Cases and Controls comprised of
asphyxiated and non-asphyxiated neonates, respectively. The urine samples from the
50 neonates comprising the cases and 50 neonates comprising the controls constituted
the material for the study.
METHOD OF COLLECTION OF DATA
The study included two groups:
The case group: It included 50 neonates fulfilling the following criteria:
Inclusion criteria:
1) Gestational age 37 weeks.
2) Appropriate for gestational age.
3) The neonates will be identified to have experienced perinatal asphyxia when at
least 3 of the following are present:
A) Intrapartum signs of fetal distress, as indicated by non reassuring
NST on continuous electronic fetal monitoring and/ or by thick
meconium staining of the amniotic fluid.
B) Apgar score of <7 at one minute of life.
C) Resuscitation with >1 minute of positive pressure ventilation before
stable spontaneous respiration.
72

D) Profound metabolic or mixed acidemia (pH<7.00) in an umbilical

artery blood sample, if obtained.
E) Mild, moderate or severe hypoxic ischemic encephalopathy (HIE),
as defined by sarnat and sarnat 1976
77
.
Exclusion criteria:
1) Congenital malformations.
2) Maternal drug addiction.
3) Neonates born to mothers who would have received magnesium sulphate
within 4 hours prior to delivery or opiods (pharmacological depression).
4) Hemolytic disease of the newborn.
5) Neonates born to mothers consuming alcohol
6) Neonates born to mothers who are smokers
7) Neonates born to mothers on anti epileptics
The control group:
It included 50 term apparently healthy neonates appropriate for gestational age
without signs of peinatal asphyxia as evidenced by normal fetal heart rate patterns,
clear liquor and one minute Apgar score 7.
All neonates included in the study had the following done:
1) Detailed maternal history, assessment of intrauterine fetal well being by
continuous electronic fetal monitoring, meconium staining of amniotic fluid, birth
events, Apgar score, sex of the baby and weight of the baby were recorded on the
precoded proforma. Gestational age was assessed by New Ballard scoring system.
Arterial blood gas analysis (ABG) was done if umbilical arterial blood was
obtained and also depending on the availability of the facility for analysis.
73

2) Thorough clinical and neurological examination was done for all the neonates
included in the study. The asphyxiated neonates (case group) were monitored for
seizures, hypotonia and HIE in the immediate neonatal period in the NICU.
Grading system used to grade the severity of HIE was SARNAT and SARNAT
staging 1976.
77
The cases were also observed for other systemic effects of
asphyxia.
3) Urine sample were collected from the neonates and sent for: The spot urine
samples were collected within 6-24 hours of life. The procedure was carried out
using sterile urine collection bags, after which urine samples were frozen at - 20C
until analyses could be carried out. Uric acid and creatinine in single urine sample
were determined by auto analyzer as follows:
Uric acid
Urine samples were analyzed on the Roch / Hitachi 917
128
auto analyzer with
automatic sample dilution using 0.9 NaCl. Assay principle: Enzymatic colorimetric
assay using uricase as follows:
Uric acid + 2H2O + O2 ? Allantoin + CO2 + H2O2
2H2O2 + H + TOOS + 4 amino phenazone ?quinone diimine dye + 4 H2O.
The intensity of the red color is proportional to the uric acid concentration and
is measured photometrically.
129

Creatinine
Urine samples were analyzed on the Roch/Hitachi 917 (130) auto analyzer
with automatic sample dilution using 0.9 NaCl.Assay principle: Kinetic colorimetric
assay (Jaffe Method) as follows:
Creatinine + picric acid ? creatinine-picric acid complex.
In an alkaline media, creatinine forms a yellow orange complex with picrate.
74

The color intensity is proportional to the creatinine concentration and is measured

photometrically.
131

4) The case group also had other investigations and imaging studies done as required
for post-resuscitation management of asphyxiated neonates. The causes for
hypotonia, seizures, lethargy, poor feeding other than HIE were ruled out with
relevant investigations available. Peripheral smear for erythrocyte morphology
and reticulocyte count was used to document hemolytic disease of the newborn.
Statistical Methods
132-135
: Descriptive statistical analysis has been carried out in the
present study. Results on continuous measurements are presented on Mean SD
(Min-Max) and results on categorical measurements are presented in Number (%).
Significance is assessed at 5 % level of significance. The following assumptions on
data is made, Assumptions: 1.Dependent variables should be normally distributed,
2.Samples drawn from the population should be random, Cases of the samples should
be independent
Analysis of variance (ANOVA) has been used to find the significance of study
parameters between three or more groups of patients , Student t test ( two tailed,
independent) has been used to find the significance of study parameters on
continuous scale between two groups Inter group analysis) on metric parameters.
Leven1s test for homogeneity of variance has been performed to assess the
homogeneity of variance. . Chi-square/ Fisher Exact test has been used to find the
significance of study parameters on categorical scale between two or more groups.
Sample Size estimation
Mean Known Population size
75

n = { z
2
*
2
* [ N / (N - 1) ] } / { ME
2
+ [ z
2
*
2
/ (N - 1) ] }
Mean Unknown population size
n = ( z
2
*
2
) / ME
2

n = [ ( z
2
* p * q ) + ME
2
] / ( ME
2
)
ME: is the margin of error, measure of precision.
and Z is 1.96 as critical value at 95%CI
Standard deviation:
1
) (
2
_

=

n
x x
SD

1. Analysis of Variance: F test for K Population means
Objective: To test the hypothesis that K samples from K Populations with the same
mean.
The mathematical model that describes the relationship between the response
and treatment for the one-way ANOVA is given by

where Y
ij
represents the j-th observation (j = 1, 2, ...n
i
) on the i-th treatment (i = 1, 2,
..., k levels)
Limitations: It is assumed that populations are normally distributed and have
equal variance. It is also assumed that samples are independent of each other.
76

Method. Let the j

th
sample contain n
j
elements(j=1,2,K). Then the total number of
elements is

= nj N

=
nj
xij
j x.


K N
j x x
S
n
i

=


1
1
2
2
1
) . 1 (

1
) .. . (
1
1
2
2
2

K
x j x nj
S
n
i

F=S
2
2
/S
1
2
Which follows F distribution (K-1, N-K)
2.Chi-Square Test: The chi-square test for independence is used to determine the
relationship between two variables of a sample. In this context independence
means that the two factors are not related. In the chi-square test for independence
the degree of freedom is equal to the number of columns in the table minus one
multiplied by the number of rows in the table minus one
Ei
Ei Oi

=
2
2
) (

, Where Oi is Observed frequency and Ei is Expected frequency

With (n-1) df
The Assumptions of Chi-square test
The chi square test, when used with the standard approximation that a chi-square
distribution is applicable, has the following assumptions:
Random sample A random sampling of the data from a fixed distribution or
population.
77

Sample size (whole table) A sample with a sufficiently large size is assumed.
If a chi square test is conducted on a sample with a smaller size, then the chi
square test will yield an inaccurate inference. The researcher, by using chi
square test on small samples, might end up committing a Type II error.
Expected Cell Count Adequate expected cell counts. Some require 5 or
more, and others require 10 or more. A common rule is 5 or more in all cells
of a 2-by-2 table, and 5 or more in 80% of cells in larger tables, but no cells
with zero expected count. When this assumption is not met, Fisher Exact test
or Yates' correction is applied.
3. Fisher Exact Test: The Fisher Exact Test looks at a contingency table which
displays how different treatments have produced different outcomes. Its null
hypothesis is that treatments do not affect outcomes-- that the two are independent.
Reject the null hypothesis (i.e., conclude treatment affects outcome) if p is "small".
The usual approach to contingency tables is to apply the
2
statistic to each
cell of the table. One should probably use the
2
approach, unless you have a special
reason. The most common reason to avoid
2
is because you have small expectation
values
1: Fisher Exact test (rxc tables)
Let there exist two such variables and , with and observed states,
respectively. Now form an matrix in which the entries represent the number of
observations in which and . Calculate the row and column sums and ,
respectively, and the total sum
78

of the matrix. Then calculate the conditional probability of getting the actual matrix
given the particular row and column sums, given by

which is a multivariate generalization of the hypergeometric probability function.
4. Student t test (Two tailed, independent)
Assumptions: Subjects are randomly assigned to one of two groups. The
distribution of the means being compared are normal with equal variances.
Test: The hypotheses for the comparison of two independent groups are:
H
o
: u
1
= u
2
(means of the two groups are equal)
H
a
: u
1
u
2
(means of the two group are not equal)
The test statistic for is t, with n
1
+ n
2
- 2 degrees of freedom, where n
1
and n
2

are the sample sizes for groups 1 and 2. A low p-value for this test (less than 0.05 for
example) means that there is evidence to reject the null hypothesis in favor of the
alternative hypothesis. Or, there is evidence that the difference in the two means are
statistically significant. The test statistic is as follows
t-Test: Two-Sample Assuming Equal Variances
79

Pre-test: Test for variance assumption: A test of the equality of variance is used
to test the assumption of equal variances. The test statistic is F with n
1
-1 and n
2
-1
degrees of freedom.
t-Test: Two-Sample Assuming Unequal Variances


Results of the t-test: If the p-value associated with the t-test is small (< 0.05), there is
evidence to reject the null hypothesis in favor of the alternative. In other words, there
is evidence that the means are significantly different at the significance level reported
by the p-value. If the p-value associated with the t-test is not small (> 0.05), there is
80

not enough evidence to reject the null hypothesis, and you conclude that there is
evidence that the means are not different.
5. Significant figures
+ Suggestive significance (P value: 0.05<P<0.10)
* Moderately significant ( P value:0.01<P 0.05)
* Strongly significant (P value : P0.01)
Statistical software: The Statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1,
MedCalc 9.0.1 ,Systat 12.0 and R environment ver.2.11.1 were used for the analysis
of the data and Microsoft word and Excel have been used to generate graphs, tables
etc.
6.Diagnostic statistics:
Disease
Test Present n Absent n Total
Positive True Positive a False Positive c a + c
Negative False Negative b True Negative d b + d
Total a + b c + d

81

The following statistics can be defined:

Sensitivity: probability that a test result will be positive when the disease is present
(true positive rate, expressed as a percentage).
= a / (a+b)
Specificity: probability that a test result will be negative when the disease is not
present (true negative rate, expressed as a percentage).
= d / (c+d)
Diagnostic values based on Area under curve:
0.9-1.0 Excellent test
0.8-0.9 Good test
0.7-0.8 Fair test
0.6-0.7 Poor test
0.5-0.6 Fail
82

OBSERVATIONS AND RESULTS

This prospective study was conducted in Neonatal division of department of
Pediatrics, Adichunchanagiri Institute of Medical Sciences and Research Centre,
B.G.Nagara for a period of 12 months from December 2009 to December 2010. Cases
and Controls comprised of asphyxiated and non-asphyxiated neonates, respectively.
Study design: A Case study of 50 cases (Neonatal Asphyxia) and control of 50
cases(normal newborns), in Rural setting, were undertaken in assessing the Urinary
Acid /Creatinine ratio as a marker in neonatal Asphyxia
The urine samples from 50 neonates comprising the cases and 50 neonates
comprising the controls constituted the material for the study.
Table 15: Gender distribution of neonates studied
Cases Controls
Gender
No % No %
Male 30 60.0 25 50.0
Female 20 40.0 25 50.0
Total 50 100.0 50 100.0
Among the 50 neonates in case group, there were 30 (60%) males and 20
(40%) females. Among the control group of 50 neonates, there were 25 (50%) males
and 25 (50%) females.Samples are gender matched with p=0.315

83

Male
60.0%
Female
40.0%
Cases

Figure:7. Shows gender distribution of neonates studied.
Male
50.0%
Femal e
50.0%
Cont rols
84

Table 16: Gestational age of neonates studied

Cases Controls
Gestational
age
No % No %
Term 32 64.0 50 100.0
Post dated 13 26.0 0 0.0
Post term 5 10.0 0 0.0
Total 50 100.0 50 100.0
Amoung 50 asphyxiated neonates which formed the case group 32(64%) were
term gestation,13(26%) were post dated and 5(10%) were post term according to
gestation where as all normal neonates which constituted the control group were term
gestationally.Gestational age distribution is statistically similar with p=0.277 (not
stasistically significant)
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
s
Ter m Post dated Post ter m
Cases
Control s
Gestational age

Figure:8. shows gestational age distribution of neonates studied
85

Table 17: Birth weight of neonates studied

Cases Controls
BW (kg)
No % No %
2.50-3.00 38 76.0 29 58.0
3.00-3.50 8 16.0 15 30.0
3.50-4.00 4 8.0 6 12.0
>4.00 0 0.0 0 0.0
Total 50 100.0 50 100.0
Mean SD 2.920.36 3.020.38
Among the 50 neonates in case group, 38 (76%) neonates weighed between
2.5-3.0 kg, 8 (16%) weighed between 3.0-3.5 kg and 4 (8%) weighed > 3.5 kg.
Among the control group of 50 neonates, 29 (58%) neonates weighed between 2.5-3.0
kg, 15 (30%) weighed between 3.0-3.5 kg and 6 (12%) weighed > 3.5 kg. The mean
weight in case group was 2.920.36 kg and in control group was 3.020.38 kg. Birth
weight distribution is statistically similar with P=0.13.
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
s
2.50-3.00 3.00-3.50 3.50-4.00 >4.00
Cases
Cont r ols
BW (kg)

Figure:9. Shows birth weight distribution of neonates studied.
86

Table 18: Maternal History of neonates studied

Cases Controls
Maternal
History
No % No %
Primi 28 56.0 26 52.0
Multi 22 44.0 24 48.0
Total 50 100.0 50 100.0
Among the 50 neonates in case group, 28 (56%) were born to primi mothers
and 22 (44%) were born to multi gravida mothers. Among the control group of 50
neonates, 26 (52%) were born to primi mothers and 24 (48%) were born to multi
gravida mothers. Proportion of primi and multi gravid mothers are statistically similar
with P=0.057.
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
s
Pri mi Mult i
Cases
Cont rol s
Maternal History

Figure:10. Shows maternal history of neonates studied
87

Table 19: Mode of delivery of neonates studied

Cases Controls
Mode of
delivery
No % No %
Normal 28 56.0 49 98.0
Instrumental 5 10.0 0 0.0
LSCS 17 34.0 1 2.0
Total 50 100.0 50 100.00
Among the 50 neonates in case group, 28 (56%) neonates were delivered
normally, 17 (34%) were delivered by cesarean section and 5 (10%) had instrumental
delivery. Among the control group of 50 neonates, 49 (66%) had normal delivery, 1
(2%) neonates were delivered by cesarean section and 1 none had instrumental
delivery.Incidence of cesarean section and instrumental delivery are significantly
more in case group (88%) compared to control group (34%) with P<0.001.
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
s
Nor mal Instr umental LSCS
Cases
Cont rol s
Mode of delivery

Figure 11: showing the mode of delivery of the neonates studied
88

Table 20: Presenting part at the time of delivery of neonates studied

CASES(n=50) CONTROLS(n=50) PRESENTING PART
NO % NO %
VERTEX 44 88 49 98
BREECH 04 08 1 02
SHOULDER 02 04 0 0
BROW 0 0 0 0
Among the 50 neonates in case group, 44 (88%) neonates had cephalic
presentation, 4 (8%) had breech presentation, 2 (4%) had shoulder presentation and
non had brow presentation. Among the control group of 50 neonates, 49 (98%) had
cephalic presentation, 1 (2%) neonates had breech presentation and none had shoulder
or brow presentation. The cases and control group were statistically similar with
P=0.658.

89

Table 21: Signs of Fetal Distress of neonates studied

Cases
(n=50)
Controls
(n=50) FD
No % No %
NST
Reactive 7 14.0 50 100.0
Non-reactive 43 86.0 0 0.0
TMSAF
Negative 27 54.0 50 100.0
Positive 23 46.0 0 0.0
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
s
Reacti ve Non-r eac tiv e
Cases
Cont rol s
NST

Figure 12: showing the NST(non stress test) of the neonates studied
90

Among the 50 neonates in case group, 7 (14%) had Reassuring NST and 43
(86%) had Non Reassuring NST suggestive of fetal distress. All the 50 (100%)
neonates in control group had Reassuring NST. Incidence of Non Reassuring NST is
significantly more in case group (78.0%) against control group with P=0.004.
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
s
Negativ e Pos iti ve
Cases
Cont rol s
TMSAF

Figure 13: showing the mode of delivery of the neonates studied
Among the 50 neonates in case group, 27 (54%) had Thick MSAF and in 23
(46%) the amniotic fluid was clear. All the 50 (100%) neonates in control group clear
amniotic fluid. Incidence of thick MSAF was significantly more in cases when
compared controls with p<0.005.
91

Table 22: Apgar score of neonates studied

Cases Controls
Apgar score
No % No %
At 1 minute
<7.0 50 100.0 0 0.0
>7.0 0 0.0 50 100.0
At 5 minute
<7.0 18 36.0 0 0.0
>7.0 32 64.0 50 100.0
At 10 minute
<7.0 9 18.0 0 0.0
>7.0 41 82.0 50 100.0

92

Table 23: Apgar score further subdivided of neonates studied

Cases (n=50) Control (n=50)
Apgar score
No % No %
Apgar score at 1 min
0-3 45 90.0 0 0.0
4-6 5 10.0 0 0.0
7.0 0 0.0 50 100.0
Apgar score at 5 min
0-3 7 14.0 0 0.0
4-6 11 22.0 0 0.0
7.0 32 64.0 50 100.0
Apgar score at 10 min
0-3 0 0.0 0 0.0
4-6 9 18.0 0 0.0
7.0 41 82.0 50 100.0
All the 50 (100%) neonates in the case group had an Apgar score of <7 at 1
min. 45 (90%) had an Apgar score between 0-3 (severe birth asphyxia) and 5 (10%)
had Apgar score between 4-6 (moderate birth asphyxia).Of the 50 (100%) neonates in
the case group18 had an Apgar score of <7 at 5 min.7(14%) had an Apgar score
between 0-3 (severe birth asphyxia) and 11 (22%) had Apgar score between 4-6
(moderate birth asphyxia) remaining 32(64%) cases had Apgar score of >7 at 5 min.
93

Of the 50 (100%) neonates in the case group 9 had an Apgar score of <7 at 10
min.None had an Apgar score between 0-3 (severe birth asphyxia) and 9 (18%) had
Apgar score between 4-6 (moderate birth asphyxia) remaining 41 cases had Apgar
score of >7 at 10 min







Figure 14: showing the APGAR score at 1 minute of the neonates studied
Amoung the 50 neonates in case group, all the 50 (100%) neonates had an
Apgar score of <7 at 1 min.All the 50 (100%) neonates in control group had an Apgar
score 7. Incidence of Apgar score <7 is significantly more in cases (100.0%) at 1
min with P<0.001. there by being helpful as an important tool for birth asphyxia
diagnosis and its severity.
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
s
<7.0 >7.0
Cases
Contr ol s
94

0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
s
<7.0 >7.0
Cases
Cont rol s
At 5 minute

Figure 15: showing the APGAR score at 5 minutes of the neonates studied
Among the 50 neonates in case group, all the18 (36%) neonates had an Apgar
score of <7 at 1 min and 32(64%) had above 7 APGAR.All the 50 (100%) neonates in
control group had an Apgar score 7. Incidence of Apgar score <7 is significantly
more in cases (100.0%) at 5 min with P<0.001 there by being helpful as an important
tool for birth asphyxia diagnosis and its severity.
95

0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
s
<7.0 >7.0
Cases
Cont rol s
At 10 minute

Figure 16: showing the APGAR score at 10 minutes of the neonates studied
Among the 50 neonates in case group, all the 9 (18%) neonates had an Apgar
score of <7 at 5 min and 41(82%) had a APGAR of >7.All the 50 (100%) neonates in
control group had an Apgar score 7. Incidence of Apgar score <7 is significantly
more in cases (100.0%) at 1 min with P<0.001. there by being helpful as an important
tool for birth asphyxia diagnosis and its severity.

96

Table 24: RESUSCITATION WITH >1 MINUTE OF POSITIVE PRESSURE

VENTILATION required for the neonates studied
Cases Controls
Resuscitation
No % No %
Negative 0 0.0 50 100.0
Positive 50 100.0 0 0.0
Among the 50 neonates in case group, all the 50 (100%) neonates were in
need of RESUSCITATION with >1 minute of positive pressure ventilation before
stable spontaneous respiration.All the 50 (100%) neonates in control group were not
in need of any such intervention cases (100.0%) with a P<0.001.
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
s
Negativ e Pos iti ve
Cases
Cont rol s
Resuscitation

Figure 17: showing the need for resuscitation of the neonates studied

97

Table 25: showing the arterial pH of the neonates studied

ABG No of patients (n=50) %
7.1-7.15 5 10.0
7.15-7.20 3 6.0
7.20-7.25 13 26.0
7.25-7.30 17 34.0
7.30-7.35 8 16.0
7.35-7.40 2 4.0
7.40-7.45 2 4.0
Out of the 50 cases of neonatal asphyxia studied 5(10%) of the neonates had
arterial pH between 7.1-7.15, 3(6%) of the neonates had arterial pH between 7.15-7.2,
13(26%) of the neonates had arterial pH between 7.2-7.25, 17(34%) of the neonates
had arterial pH between 7.25-7.3, 8(16%) of the neonates had arterial pH between
7.3-7.35, 2(4%) of the neonates had arterial pH between 7.35-7.4, 2(4%) of the
neonates had arterial pH between 7.4-7.45.
10
6
26
34
16
4 4
0
5
10
15
20
25
30
35
40
45
50
P
e
r
c
e
n
t
a
g
e
s
7.1-7.15 7.15-7.20 7.20-7.25 7.25-7.30 7.30-7.35 7.35-7.40 7.40-7.45
ABG

Figure 18: showing the arterial pH of the neonates studied
98

Table 26: Neurological Examination of the neonates studied

Neurological Examination No of patients (n=50) %
Tone
Normal 30 60.0
Flaccid 6 12.0
Decreased 14 28.0
Seizures
Negative 30 60.0
Positive 20 40.0
60
12
28
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
s
Nor mal Flaccid Decreased
Tone

Figure 19 : showing the tone of neonates studied
Among the 50 neonates in case group, 30 (60%) had normal neurological
examination with normal tone. 14 (28%) had mild and marked hypotonia and 6 (12%)
were flaccid with severe hypotonia. All the 50 (100%) neonates in control group had
99

normal neurological examination. Abnormal neurological examination is significantly

more (40.0%) in cases when compared to Controls with P<0.001.
Positive
40%
Negative
60%
Seizures

Figure 20 : showing the number of neonates studied havin seizures
Among the 50 neonates in case group, 30 (60%) had normal neurological
examination with no seizures. 20 (40%) had seizures as an abnormal nerulogical
examination finding . Abnormal neurological examination is significantly more
(40.0%) in cases when compared to Controls with P<0.001.
100

Table 27: Incidence of HIE (HYPOXIC ISCHEMIC ENCEPHALOPATHY)

amoung neonates studied
HIE No of patients (n=50) %
Not in HIE 14 28.0
Stage I 16 32.0
Stage II 14 28.0
Stage III 6 12.0
Stages classified as per sarnat and sarnat classification of hypoxic ischemic
encephalopathy 1976
28
32
28
12
0
5
10
15
20
25
30
35
40
45
50
P
e
r
c
e
n
t
a
g
e
s
Not in HIE St age I St age I I Stage III
HIE

Figure 21:showing HIE staging of asphyxiated neonates
Among the 50 neonates in the case group, 14(28%) were not in HIE, 16(32%)
had mild HIE, 14(28%) had moderate HIE and 6(12%) had severe HIE during the
course in NICU.
101

Table 28:Outcome of neonates enrolled in the case group having suffered

asphyxia
Outcome No of patients (n=50) %
Discharge 42 84.0
DAMA 6 12.0
Death 2 4.0

84
12
4
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
s
Dis char ge DAMA Deat h
Out come

Figure 22:showing outcome of asphyxiated neonates
Out of 50 neonates enrolled in the case group having suffered asphyxia
42(84%) were discharged,6(12%) were discharged against medical advice,2(4%)
died.
102

Table 29: Comparison of UUA/Cr ratio in two groups studied

UUA/Cr Cases` Controls
Min-Max 0.78-4.94 0.42-1.14
Mean SD 2.581.09 0.860.17
Inference
UUA/Cr ratio is significantly higher in study
group compared to Control with t=11.052;
P<0.001**
0
0.5
1
1.5
2
2.5
3
3.5
4
Cont r ol Cases
U
U
A
/
C
r

Figure 23: Comparison of UUA/Cr ratio in two groups studied
UUA/Cr ratio is significantly higher in study group compared to Control with
t=11.052; P<0.001
103

Table 30: Correlation of clinical variables with HIE status in cases studied
HIE stage
Variables
Total
number of
patients
(n=50)
Normal
(n=14)
Stage I
(n=16)
Stage II
(n=14)
Stage III
(n=6)
P value
Maternal History
Primi 28(56%) 11(78.6%) 9(56.3%) 4(28.6%) 4(66.7%)
Multi 22(44%) 3(21.4%) 7(43.8%) 10(71.4%) 2(33.3%)
0.057+
Gestational age
Term 32(64%) 9(64.3%) 12(75%) 8(57.1%) 3(50%)
Post dated 13(26%) 5(35.7%) 2(12.5%) 5(35.7%) 1(16.7%)
Post term 5(10%) 0(0%) 2(12.5%) 1(7.1%) 2(33.3%)
0.277
Mode of delivery
Normal 28(56%) 9(64.3%) 6(37.5%) 10(71.4%) 3(50%)
Instrumental 5(10%) 1(7.1%) 2(12.5%) 0(0%) 2(33.3%)
LSCS 17(34%) 4(28.6%) 8(50%) 4(28.6%) 1(16.7%)
0.229
NST
Reactive 7(14%) 6(42.9%) 0(0%) 1(7.1%) 0(0%)
Non-reactive 43(86%) 8(57.1%) 16(100%) 13(92.9%) 6(100%)
0.004**
TMSAF
Negative 23(46%) 7(50%) 7(43.8%) 5(35.7%) 4(66.7%)
Positive 27(54%) 7(50%) 9(56.3%) 9(64.3%) 2(33.3%)
0.648
ABG
7.1-7.15 5(10.0%) 0 0 0 5(83.3%)
7.15-7.20 3(6.0%) 0 0 2(14.3%) 1(16.7%)
7.20-7.25 13(26.0%) 0 1(6.3%) 12(85.7%) 0
7.25-7.30 17(34.0%) 3(21.4%) 14(87.5%) 0 0
7.30-7.35 8(16.0%) 7(50.0%) 1(6.3%) 0 0
7.35-7.40 2(4.0%) 2(14.3%) 0 0 0
7.40-7.45 2(4.0%) 2(14.3%) 0 0 0
Mean SD 7.260.07 7.350.05 7.280.02 7.220.02 7.130.02
<0.001**
Outcome
Discharge 42(84%) 14(100%) 15(93.8%) 11(78.6%) 2(33.3%)
DAMA 6(12%) 0(0%) 1(6.3%) 3(21.4%) 3(50%)
Death 2(4%) 0(0%) 0(0%) 0(0%) 2(33.3%)
<0.001**
104

0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
Normal St age I St age II St age III
Primi Mult i
Maternal History
HIE stage

Figure 24: Correlation of maternal history with HIE status in cases studied
Table 30 and figure 24 displayed the correlation whether maternal history
affects HIE status amoung the cases and it was found to be statistically not significant
with a p value of 0.057
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
Normal Stage I Stage II Stage III
Post ter m
Post dated
Ter m
Gestational age
HIE stage

Figure 25: Correlation of gestational age with HIE status in cases studied
105

Table 30 and figure 25 displayed the correlation whether gestational age

affects HIE status amoung the cases and it was found to be statistically not significant
with a p value of 0.27






Figure 26:Correlation of non stress test whether reactive or non reactive which is
an indicator of fetal distress with HIE status in cases studied
Table 30 and figure 26 displayed the correlation of non stress test whether
reactive or non reactive which is an indicator of fetal distress affects HIE status
amoung the cases and it was found to be statistically significant with a p value of
0.004
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
Normal Stage I Stage II Stage III
Non-r eactive
Reacti ve
NST
106

0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
Nor mal St age I St age II St age III
Posi t i ve
Negat i ve
TMSAF
HIE stage

Figure 27: Correlation of thick meconium staining of liquor which is an indicator
of fetal distress with HIE status in cases studied
Table 30 and figure 27 displayed the correlation of thick meconium staining of the
liquor which is an indicator of fetal distress affects HIE status amoung the cases and it
was found to be statistically not significant with a p value of 0.648
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
Normal Stage I Stage II Stage III
7.40-7. 45
7.35-7. 40
7.30-7. 35
7.25-7. 30
7.20-7. 25
7.15-7. 20
7.1-7.15
HIE st age
ABG

Figure 28: Correlation of ABG (arterial pH) with HIE status in cases studied
107

Table 30 and figure 28 displayed the correlation of arterial pH( acidosis is an

indicator of neonatal asphyxia) with HIE status amoung the cases and it was found to
be statistically significant with a p value of < 0.001 there by being helpful as an
important tool for birth asphyxia diagnosis and its severity.
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
Normal St age I Stage II St age III
Deat h
DAMA
Discharge
Outcome
HIE stage

Figure 29: Correlation of outcome of cases with HIE status in cases studied
Table 30 and figure 29 displayed the correlation ofoutcome with HIE status
amoung the cases and it was found to be statistically significant with a p value of <
0.001.with both deaths being recorded amoung the asphyxiated neonates belonging to
HIE stage 3.
108

Table 31: Correlation of urinary uric acid and creatinine ratio(UUA/Cr) with
HIE status in cases studied
HIE stage
UAA/Cr
Total number
of patients
(n=50)
Not in
HIE
(n=14)
Stage I
(n=16)
Stage II
(n=14)
Stage III
(n=6)
P value
Min-Max 0.78-4.94 0.78-2.65 1.62-3.48 2.18-3.92 3.72-4.94
Mean SD 2.581.09 1.350.57 2.700.66 2.900.56 4.370.43
<0.001**


Figure 30: Comparison of urinary uric acid and creatinine ratio(UUA/Cr) with
HIE status in cases studied
Table 31 and figure 30 displayed the correlation of of urinary uric acid and
creatinine ratio(UUA/Cr ) with HIE status amoung the cases and it was found to be
statistically significant with a p value of < 0.001
0
1
2
3
4
5
6
Not in HIE Stage I Stage II Stage III
UAA/Cr
109

Table 32: Correlation of Apgar score with HIE status in cases studied
HIE stage
Apgar score
Total
number of
patients
(n=50)
Normal
(n=14)
Stage I
(n=16)
Stage II
(n=14)
Stage III
(n=6)
P value
At 1 minute
<7.0 50(100.0%) 14(100.0%) 16(100.0%) 14(100.0%) 6(100.0%)
>7.0 0 0 0 0 0
Mean
SD
2.841.72 4.141.09 3.251.84 1.861.17 1.000.00
NS
At 5 minute
<7.0 18(36.0%) 1(7.1%) 1(6.3%) 10(71.4%) 6(100.0%)
>7.0 32(64.0%) 13(92.9%) 15(93.8%) 4(28.6%) 0
Mean
SD
6.881.85 8.070.99 7.810.75 6.001.66 3.670.82
<0.001**
At 10 minute
<7.0 9(18.0%) 0 0 4(28.6%) 5(83.3%)
>7.0 41(82.0%) 14(100.0%) 16(100.0% 10(71.0%) 116.7%)
Mean
SD
7.741.14 8.500.65 8.190.54 7.140.95 6.171.47
<0.001**
110

0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
Nor mal Stage I Stage II Stage III
<7.0 >7.0
Apgar score at
1 min
HIE st age

Figure 31: Correlation of Apgar score at 1 min with HIE status in cases studied
Table 32 and figure 31 displayed the correlation of APGAR score at 1 min
with HIE status amoung the cases and it was not found to be statistically significant.
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
Nor mal Stage I Stage II Stage III
<7.0 >7.0
Apgar score at
5 min
HIE st age

Figure 32: Correlation of Apgar score at 5 min with HIE status in cases studied
111

Table 32 and figure 32 displayed the correlation of APGAR score at 5 min

with HIE status amoung the cases and it was found to be statistically significant with
p value of < 0.001 there by being helpful as an important tool for birth asphyxia
diagnosis and its severity.
0
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
Nor mal Stage I Stage II Stage III
<7.0 >7.0
Apgar score at
10 min
HIE st age

Figure 33: Correlation of Apgar score at 10 min with HIE status in cases studied
Table 32 and figure 33 displayed the correlation of APGAR score at 10 min
with HIE status amoung the cases and it was found to be statistically significant with
a p value of < 0.001 there by being helpful as an important tool for birth asphyxia
diagnosis and its severity.
112

Table 33: Shows sensitivity, specificity and predictive values of UAA/Cr in

prediction of Neo-natal asphyxia
UAA/Cr Sensitivity Specificity PPV NPA Accuracy
Area
Under
ROC
P value
>1.14 84.00 94.00 93.33 85.45 89.00 0.963 <0.001**
PPV- Positive predictive value, NPV- Negative predictive value, AUROC-
Area Under Receiving operating Characteristic.
The cut-off UAA/Cr value of >1.14 has 84% sensitivity with a specificity of
94% and has a positive predictive value of 93.33% with a negative predictive value of
85.45%.With an accuracy of 89%.
UUA_Cr
0 20 40 60 80 100
100
80
60
40
20
0
100-Specificity
S
e
n
s
i
t
i
v
i
t
y

Figure 34: ROC analysis of UAA/Cr to prediction of Neo-natal asphyxia
113

DISCUSSION
Perinatal asphyxia is a common neonatal problem and contributes significantly
to neonatal morbidity and mortality. Birth asphyxia is a common and important cause
of preventable cerebral injury occurring in the neonatal period, but although asphyxia
at birth is a commonly made diagnosis, there is generally no accepted definition for it.
Perinatal asphyxia is a devastating clinical condition because of its potential for
causing permanent damage, even death of the fetus or newborn infant. The value of
present biochemical markers for diagnosing asphyxia is inadequate
and controversial
117
. Prediction of outcome of perinatal asphyxia is important but
formidable
136
.The Apgar score has a limited role in predicting the immediate
outcome,such as that of HIE and the long-term sequelae
82
. Several studies have shown
that cerebral function monitoring using non invasive techniques, such as EEG within
six hours of birth, cranial ultrasonography, cranial topography, doppler measurements
of cerebral blood flow, somato-sensory evoked potentials, magnetic resonance
imaging and estimation of neurophysiological markers such As CK-BB, brain specific
LDH isomer, glutamate and neurone specific enolase in the cerebrospinal fluid are all
useful in predicting both the immediate dysfunction and the long term outcome
136, 137,
138
. But none of these facilities are routinely available except in few tertiary hospitals
and in some of the teaching hospitals of our country. Other factors like poverty,
ignorance and lack of medical facilities and obstetric care contributes significantly to
the magnitude of the problem in our country. Only a third of deliveries in India are
institutional and many asphyxiated babies are brought late to hospitals
3
. The signs of
asphyxial injury are nonspecific and overlap with other illnesses. In the absence of
perinatal records, it is difficult to retrospectively diagnose perinatal asphyxia. The
114

current problem then becomes our inability to precisely distinguish the false positive
affected from the true positive asphyxiated or compromised fetus. Several studies
have been conducted to evaluate better markers that help to differentiate asphyxial
and non-asphyxial etiology in neonates.
In the present study an attempt has been made to ascertain whether urinary
uric acid and creatinine ratio(UUA/Cr) can distinguish an asphyxiated from a non-
asphyxiated term neonate. These tests are routinely available in most centres and
hence a comparative study was done to establish the usefulness based on previous
studies.an attempt was also made to find out whether Apgar score is still an important
tool for birth asphyxia diagnosis and its severity.
In humans, UA is the end product of purine metabolism
118
. It is derived from
either the increased turnover of purines or from the increased catabolism of tissue
nucleic acids. Two isoenzymes, xan thine oxidase and dehydrogenase, de grade the
purines, xanthine and hypoxanthine, to UA. Xanthine dehy drogenase produces UA
and reduced nicotinamide adenine dinucleotide, and xanthine oxidase produces UA
and su peroxide. Under certain conditions such as hypoxia or ischemia, there is
increased conversion of the dehydrogenase form to the oxidized form. UA is a poorly
soluble acid that requires continuous ex cretion by the kidneys to avoid toxic
accumulation. Because of its poor solubility, alterations in its production or excretion
can produce high serum levels.
119,120

The renal elimination of uric acid involves four components: glomerular
filtration, tubular reabsorption, tubular secretion and reabsorption beyond secretory
sites. Increased excretion of uric acid may be caused by metabolic changes, reflecting
115

cellular hypoxia or by renal changes. During reoxygenation after asphyxia or during

reperfusion after ischemia, hypoxanthine which accumulated in both circulating blood
and tissues is oxidized to uric acid
121
.
Because urinary creatinine can be used as the reference substrate in a spot
urine sample, an increased UA/Cr ratio (as a sign of increased ATP degradation) may
be a valuable indicator of the severity of tissue hypoxia in patients with intact renal
functions
122
.
The present study revealed significant increase in UA/Cr ratio in early spot
urine samples from asphyxiated full term newborns and the study proved positive
correlation between the urinary UA/Cr ratio and the severity (grading) of HIE (P<
0.001) . In the study the two infants with the highest UA /Cr ratio died in the early
neonatal period.
The results of the present study were in concordance with those of Reem
Mahmoud and Dina El Abd(2010) who reported Urinary UA/Cr ratios were higher in
asphyxiated infants (2.9 0.73) when compared with the controls (0.720.35,
P<0001). UA/Cr ratios were significantly higher in infants with severe HIE (3.I8 0.6
1) when compared with infants with moderate HIE (2.190.32: P<0.01) and those
with mild HIE (1.53 0.25: P<0.001). The values of the UA/Cr ratios in the mild and
moderate HIE groups (group Ia vs Ib) were also statistically significant (P < 0.01).
42

Following table 34 shows the above study also found sex of the baby and birth
weight of the neonate not to be statistically significant difference between the cases an
control groups. But mode of delivery was found to be statistically significant in both
studies with the cases group having statistically significant more number of
116

instrumental deliveries as well as cesarean sections. Following table also shows that
in both studies APGAR SCORE at 1 minute ,5 minute,10 minute to statistically
significant between the case an the control group there by being helpful as an
important tool for birth asphyxia diagnosis and its severity. Following table also adds
arterial pH shows a statistically significant difference between the cases an control
groups
Table 34: . Comparative study of baseline characteristics of cases and
controls.between our study an as reported by Reem Mahmoud and Dina El Abd
42

Reem Mahmoud and
Dina El Abd
Present study

P value
Characteristics
Cases
(n=40)
Controls
(n=20)
Cases
(n=50)
Controls
(n=50)

male 40% 70% 60% 50%
Not
significant sex
female 60% 30% 40% 50%
normal 56% 98%

instrumental
70% 80%
10% 0%
<0.005
Mode
of
delivery
cesarean 30% 20% 34% 2%
<0.005
Birth weight 3.250.543 3.320.442 2.920.36 3.020.38
Not
significant
APGAR 1min
5 min
10 min
1(0-1)
3(1-5)
-

9(8-10)
9(9-10)
-
2.841.72
6.881.85
7.741.14
>7
>8
>9

<0.001
<0.001
<0.001
Arterial pH
6.98
0.15
7.32 0.08 7.260.07 7.40.04

<0.001
Urinary uric acid and
creatinine ratio
2.9 0.73 0.720.35 2.581.09 0.860.17

<0.001
117

In the above study a significant correlation was detected between the UA/Cr
ratio and the severity of HIE in the asphyxiated group ( P < 0.001) similar to what we
have reported as shown in table 33 and 34.
Table 35: The urinary uric acid / creatinine ratio in relation to HIE reported by
Reem Mahmoud and Dina El Abd
42

Mild HIE Moderate
HIE
Severe HIE controls
Number 16 16 8 20
UA/Cr 1.53 0.25 2.190.32 3.I8 0.6 1 0.720.35
Range 1.02-2.11 1.68-2.69 2.25- 4.54 0.20-1.22
Asphyxiated neonates classified into 3 groups as per sarnat and sarnat staging
1976 similar to that used in our study
Table 36: Correlation of UAA/Cr with HIE status in our case
HIE stage
UAA/Cr
Total number
of patients
(n=50)
Normal
(n=14)
Stage I
(n=16)
Stage II
(n=14)
Stage III
(n=6)
P value
Min-Max 0.78-4.94 0.78-2.65 1.62-3.48 2.18-3.92 3.72-4.94
Mean SD 2.581.09 1.350.57 2.700.66 2.900.56 4.370.43
<0.001**
The 2 infants who died with severe HIE had the highest UA/Cr ratios (4.54,
and 4.50) as reported by the above study which is similar to our study also in which
the highest UA/Cr ratios (4.68, and 4.94) who were classified into HIE stage 3
expired.
118

Table 37:Comparative study of baseline characteristics of cases and

controls.between our study an as reported by Pallab Basu et al
34

In above study by Pallab Basu et al(2008) it was found that urinary UA/Cr
ratio was significantly higher in cases than controls (3.1 1.3 vs 0.96 0.54; p <
0.001) which is similar to our study as shown in table 35. It was also found that there
was significant difference between Apgar scores of cases than controls (3.8 1.4 vs
9.60 0.38; p = 0.02). Mean urinary UA/Cr ratio for Apgar score 4 6 were
1.970.32 vs 0.96 0.54; p < 0.003(cases vs. controls) and Apgar score 0 3 were
4.240.81 vs 0.96 0.54; p < 0.001 (cases vs. controls). There were also significant
Pallab Basu et al Present study P value
Characteristics
Cases
(n=31)
Controls
(n=31)
Cases
(n=50)
Controls
(n=50)

male 48% 61% 60% 50%
Not
significant
sex
female 52% 39% 40% 50%
normal 56% 98%

instrumental
39% 84%
10% 0%
<0.005
Mode
of
delivery
cesarean 61% 16% 34% 2%
<0.005
Birth weight
2.42
0.44 kg
2.56
0.52 kg
2.920.36 3.020.38
Not
significant
APGAR 1min
5 min
10 min

Min 2.43
max 5.24
-
Min 9.50
max 9.77

2.841.72
6.881.85
7.741.14
>7
>8
>9

<0.001
<0.001
<0.001
Urinary uric acid and
creatinine ratio
3.1 1.3
0.96
0.54
2.581.09 0.860.17
<0.001
119

differences of mean urinary UA/Cr ratio for Apgar score 4 6 vs Apgar score 0 3 (p
< 0.001) which is also similar 2 our study where apgar at 1 min,5 min and 10 min
were found to be useful in diagnosis of asphyxia and its severity.
Table 38:Comparative study of baseline characteristics of cases and
controls.between our study an as reported by BADER et al
39

This study by BADER et al(1995) UA/Cr was higher in the asphyxiated group
when compared to controls. (2,06 + 1.12, vs.
0.64 + 0.48; P < 0.001) which is similar to our study as shown in table 35
BADER et al Present study P value
Characteristics
Cases (n=18)
Controls
(n=50)
Cases
(n=50)
Controls
(n=50)

normal 56% 98%

instrumental
28% +33%
90%
10% 0%
<0.005
Mode
of
delivery
cesarean
39%
10% 34% 2%
<0.005
Birth weight
331 3211 + 45

+ 45+ 450
2.920.36 3.020.38
Not
significant
APGAR 1min
5 min
10 min
Min 2.43
max 5.24
-
Min 9.50
max 9.77

2.841.72
6.881.85
7.741.14
>7
>8
>9

<0.001
<0.001
<0.001
Urinary uric acid and
creatinine ratio
2. 2.06. 1.12 0.64 0.48 2.581.09 0.860.17
<0.001
120

Table 39:Comparative study of results of our study an as reported by BADER et al

39

UAA/Cr
cutoff
Sensitivity Specificity PPV NPA P value
PRESENT
STUDY
>1.14 84.00 94.00 93.33 85.45 <0.001**
BADER
et al
>1.2 74% 76% 78% 72% <0.001**
The positive predictive value of Ua/Cr >1.2 was 78% and the negative
predictive value was 72%.The sensitivity was 74% and specifity 76%.which was
similar to our study as shown in table 36 on difference being we had taken the cut off
value of Ua/Cr>1.14.
Table 40:Comparative study of results of our study an as reported by CHEN et al
36

UUA/Cr
CASES
UUA/Cr
CONTROLS
UAA/Cr
cutoff
Sensitivity Specificity PPV NPA P value
PRESENT
STUDY
2.581.09 0.860.17 >1.14 84.00 94.00 93.33 85.45 <0.001**
CHEN et
al
1.53 +/-
0.71
vs 0.73 +/-
0.45
>1.2 74% 76% 78% 72% <0.005
Our results support those of Chen et al(1999). who suggested that urinary ratio
of UA to creatinine was significantly higher in both full term and preterm infants with
perinatal asphyxia than in those without PA. He proved that when the urinary ratio of
UA /Cr was greater than 0.95, PA was identified with sensitivity of 80% and a
121

specificity of 71% in term infants and in preterms a cut off value of UA / Cr of 2.9
had a sensitivity of 71% and a specificity of 70% in daignosing perinatal asphyxia.
36

In agreement with our results Banupriya et al(2008). reported that urinary
excretion rate of uric acid in addition to malondialdehyde and proteins are
significantly higher in PA and correlates with APGAR and the severity of HIE.
Moreover he stated that a cut off value of 2.34 Uric Acid / mg of creatinine can
predict impending death in PA. This coincided with our results in which two hypoxic
newborns who died had U A / Cr ratio of 4.68, and 4.94 . He concluded in parallel to
our conclusion that urinary UA/Cr ratio has potential to act as biochemical marker for
severity evaluation and death predicition
40
.
The results of the present study were in concordance with those of Akisu et
al(2007). who reported elevated urinary UA/ CR ratio in full term infants with PA and
that the ratio correlates with the severity of HIE. . The UA/Cr ratio was higher in the
asphyxiated group when compared with controls (2.11 0.83 vs0.72 0.39 P <
0.001). Furthermore, there was a correlation between the UA/Cr ratio and the severity
of the encephalopathy (P < 0.001). The UA/Cr ratio was found to be a good, simple
screening test for the early assessment of perinatal asphyxia.
38

Mehes et al
123
who reported elevated urinary UA/ CR Ratio in full term infants
with PA and that the ratio correlates with the severity of HIE. They concluded that
UA/ Cr ratio is a good and simple screening test for the early assessment of perinatal
asphyxia. which was similar to our study
Lofty M. El-Sayed et al in his study showed that urinary uric acid to creatinine
ratio in term and preterm infants was significantly higher in the asphyxia group than
122

in the non asphyxiated group. simultaneously he also proved that this ratio was 80%
accurate, 76.6% sensitive,83% specific;with a positive predictive value of 82.1% and
negative predictive value of 78.1% therby concluding that this test allows rapid
recognition of asphyxia, assessment of its severity and potential to predict short term
morbidity or death as well as long term outcome an these above observations are in
concordance with our study.
37

G.Ciler Erdag,MD;A.Vitrinel,MD) showed that mean uric acid and creatinine
ratio within 24hours of birth in asphyxiated neonates was more than the mean ratio for
non asphyxiated neonates this conclusion supports our study.
35

Dong Wen Bin, et al displayed in his study that neonates who have suffered
asphyxia have higher urinary uric acid to creatinine ratio as compared to the non
asphyxiated ones. It might be used as an indicator for early assessment of severity of
asphyxia and post asphyxia renal injury in neonates.this observation is in concordance
with ours.
41

Naithani M Department of Biochemistry, Sri Guru Ram Rai Institute of
Medical Sciences, Deheradun, India, Dr. Ashish Kumar Simalti, MBBS, MD. Graded
Specialist in Paediatrics, Military Hospital, Agra. Noticed serum protein S-100,
brain-specific creatine kinase, neuron- specific enolase, IL6 and urinary uric acid
levels appear promising in identifying patients with a risk of developing hypoxic-
ischemic encephalopathy which helps substantiate our study.
43

On the contrary Tekgul et al.
117
found that measurement of interleukin 6 in
CSF with a cut off value of 25.9pg/ml had the highest predictive value among all
other biochemical markers of perinatal asphyxia. He suggested that measuring
123

interleukin 6 in CSF is superior to urinary UA/Cr ratio as a tool to diagnose PA and to

predict short term outcome of HIE but on the other hand the test is sophisticated,
expensive and invasive compared to urinary UA/Cr ratio which is simple, cheap and
safe hence can be used as a screening test in our NICUs.
In their studies both Jensen et al.
124
and Hasday and Grum
125
attributed the
increased UA in urine to the presence of hypoxia which is the cornerstone of our
hypothesis in this study. Jensen et al
124
reported increased excretion of uric acid in
premature infants with respiratory distress syndrome suffering from hypoxia. Hasday
& Grum
125
stated that urinary UA/Cr ratio increased over night in patients with sleep
associated hypoxemia.
In addition, Laing et al
126
reported that 24-hour urinary hypoxanthine/
creatinine ratios obtained after moderate or severe asphyxia were 4-8 times higher
than the ratio, after mild asphyxia.
Because of the large amounts of oxygen radicals that are produced in the
reoxygenation period, it is expected that high levels of uric acid are produced and
excreted in the early part of this period. In animal experiments, uric acid production
reached its peak around 10 hours after re oxygenation. Increased excretion of uric acid
can be measured in the early urine samples after delivery, but the time at which the
assay is carried out seems to be critical and therefore the assay should be performed
on the earliest void samples after the asphyxiating event.
11
The urinary UA/Cr ratio allows rapid recognition of asphyxia and assessment
of its severity and the potential for short term morbidity or death. While numerous
indicators for asphyxia are recognized, no single indicator has been found to be
124

predictive of subsequent morbidity. The Apgar scores have historically been used to
define asphyxia and attempt outcome prognostication
126
. Although several
biochemical indicators of asphyxia such as lactate, hypoxanthine, brain isoenzyme of
creatinine phosphokinase, neuron specific enolase, excitatory amino acids,
erythropoietin and vasopressin, have been reported, they are most useful as research
goals and are not available in most clinical services
127
.
However, we found the UA/Cr ratio to be a good, simple screening test for the
early assessment of perinatal asphyxia, Furthermore, there is a correlation between the
UA/Cr ratio and the severity of the encephalopathy, indicating the degree of injury at
an early stage when other quantitative methods frequently cannot be carried out.
However, this ratio does not provide further prognostic information that must be
obtained by other methods.


125

SUMMARY
This is a prospective case control study conducted over a period of 12 months
from December 2009 to November 2010 conducted in the department of
Pediatrics, Sri Adichunchanagiri Institute of Medical Sciences and Research
Centre, B.G.Nagara.
Cases and Controls comprised of asphyxiated and non-asphyxiated neonates,
respectively. The spot urine samples were collected within 6-24 hours of life
and sent for analysis constituted the material for the study.
A urinary uric acid to creatinine (UA/Cr) ratio value of >1.14 was taken as the
cut-off level. The sensitivity, specificity, Positive predictive value (PPV),
Negative predictive value (NPV) was calculated
Among the 50 neonates in case group, there were 30 (60%) males and 20
(40%) females. Among the control group of 50 neonates, there were 25 (50%)
males and 25 (50%) females.Samples are gender matched with p=0.315
Amoung 50 asphyxiated neonates which formed the case group 32(64%) were
term gestation,13(26%) were post dated and 5(10%) were post term according
to gestation where as all normal neonates which constituted the control group
were term gestationally.Gestational age distribution is statistically similar with
p=0.277 (not stasistically significant)
Among the 50 neonates in case group, 38 (76%) neonates weighed between
2.5-3.0 kg, 8 (16%) weighed between 3.0-3.5 kg and 4 (8%) weighed > 3.5 kg.
Among the control group of 50 neonates, 29 (58%) neonates weighed between
126

2.5-3.0 kg, 15 (30%) weighed between 3.0-3.5 kg and 6 (12%) weighed > 3.5
kg. The mean weight in case group was 2.920.36 kg and in control group was
3.020.38 kg. Birth weight distribution is statistically similar with P=0.13.
Among the 50 neonates in case group, 28 (56%) were born to primi mothers
and 22 (44%) were born to multi gravida mothers. Among the control group of
50 neonates, 26 (52%) were born to primi mothers and 24 (48%) were born to
multi gravida mothers. Proportion of primi and multi gravid mothers are
statistically similar with P=0.057
Among the 50 neonates in case group, 28 (56%) neonates were delivered
normally, 17 (34%) were delivered by cesarean section and 5 (10%) had
instrumental delivery. Among the control group of 50 neonates, 49 (66%) had
normal delivery, 1 (2%) neonates were delivered by cesarean section and 1
none had instrumental delivery.Incidence of cesarean section and instrumental
delivery are significantly more in case group (88%) compared to control group
(34%) with P<0.001.
Among the 50 neonates in case group, 44 (88%) neonates had cephalic
presentation, 4 (8%) had breech presentation and 2 (4%) had shoulder
presentation. Among the control group of 50 neonates, 49 (98%) had cephalic
presentation, 1 (2%) neonates had breech presentation and none had shoulder
presentation.The cases and control group were statistically similar with
P=0.658.
Among the 50 neonates in case group, 7 (14%) had Reassuring NST and 43
(86%) had Non Reassuring NST suggestive of fetal distress. All the 50 (100%)
neonates in control group had Reassuring NST. Incidence of Non Reassuring
127

NST is significantly more in case group (78.0%) against control group with
P=0.004.
Among the 50 neonates in case group, 27 (54%) had Thick MSAF and in 23
(46%) the amniotic fluid was clear. All the 50 (100%) neonates in control
group clear amniotic fluid. Incidence of thick MSAF was significantly more in
cases when compared controls with p<0.005.
All the 50 (100%) neonates in the case group had an Apgar score of <7 at 1
min. 45 (90%) had an Apgar score between 0-3 (severe birth asphyxia) and 5
(10%) had Apgar score between 4-6 (moderate birth asphyxia).Of the 50
(100%) neonates in the case group18 had an Apgar score of <7 at 5
min.7(14%) had an Apgar score between 0-3 (severe birth asphyxia) and 11
(22%) had Apgar score between 4-6 (moderate birth asphyxia) remaining
32(64%) cases had Apgar score of >7 at 5 min. Of the 50 (100%) neonates in
the case group 9 had an Apgar score of <7 at 10 min.None had an Apgar score
between 0-3 (severe birth asphyxia) and 9 (18%) had Apgar score between 4-6
(moderate birth asphyxia) remaining 41 cases had Apgar score of >7 at 10 min
Among the 50 neonates in case group, all the 50 (100%) neonates were in
need of RESUSCITATION with >1 minute of positive pressure ventilation
before stable spontaneous respiration.All the 50 (100%) neonates in control
group were not in need of any such intervention cases (100.0%) with a
P<0.001
Out of the 50 cases of neonatal asphyxia studied 5(10%) of the neonates had
arterial pH between 7.1-7.15, 3(6%) of the neonates had arterial pH between
7.15-7.2, 13(26%) of the neonates had arterial pH between 7.2-7.25, 17(34%)
128

of the neonates had arterial pH between 7.25-7.3, 8(16%) of the neonates had
arterial pH between 7.3-7.35, 2(4%) of the neonates had arterial pH between
7.35-7.4, 2(4%) of the neonates had arterial pH between 7.4-7.45.
Among the 50 neonates in case group, 30 (60%) had normal neurological
examination with normal tone. 14 (28%) had mild and marked hypotonia and
6 (12%) were flaccid with severe hypotonia. All the 50 (100%) neonates in
control group had normal neurological examination. Abnormal neurological
examination is significantly more (40.0%) in cases when compared to
Controls with P<0.001.
Among the 50 neonates in case group, 30 (60%) had normal neurological
examination with no seizures. 20 (40%) had seizures as an abnormal
nerulogical examination finding . Abnormal
neurological examination is significantly more (40.0%) in cases when
compared to Controls with P<0.001
Among the 50 neonates in the case group, 14(28%) were not in HIE, 16(32%)
had mild HIE, 14(28%) had moderate HIE and 6(12%) had severe HIE during
the course in NICU
Out of 50 neonates enrolled in the case group having suffered asphyxia
42(84%) were discharged,6(12%) were discharged against medical
advice,2(4%) died.
UUA/Cr ratio is significantly higher in study group compared to Control with
t=11.052; P<0.001
129

the correlation whether maternal history affects HIE status amoung the cases
and it was found to be statistically not significant with a p value of 0.057
the correlation whether gestational age affects HIE status amoung the cases
and it was found to be statistically not significant with a p value of 0.27
the correlation of non stress test whether reactive or non reactive which is an
indicator of fetal distress affects HIE status amoung the cases and it was found
to be statistically significant with a p value of 0.004
the correlation of thick meconium staining of the liquor which is an indicator
of fetal distress affects HIE status amoung the cases and it was found to be
statistically not significant with a p value of 0.648
displayed the correlation of arterial pH( acidosis is an indicator of neonatal
asphyxia) with HIE status amoung the cases and it was found to be statistically
significant with a p value of < 0.001 there by being helpful as an important
tool for birth asphyxia diagnosis and its severity.
the correlation ofoutcome with HIE status amoung the cases and it was found
to be statistically significant with a p value of < 0.001.with both deaths being
recorded amoung the asphyxiated neonates belonging to HIE stage 3.
the correlation of of urinary uric acid and creatinine ratio(UUA/Cr ) with HIE
status amoung the cases and it was found to be statistically significant with a p
value of < 0.001
the correlation of APGAR score at 1 min with HIE status amoung the cases
and it was not found to be statistically significant
130

the correlation of APGAR score at 5 min with HIE status amoung the cases
and it was found to be statistically significant with p value of < 0.001 there
by being helpful as an important tool for birth asphyxia diagnosis and its
severity.
The correlation of APGAR score at 10 min with HIE status amoung the cases
and it was found to be statistically significant with a p value of < 0.001 there
by being helpful as an important tool for birth asphyxia diagnosis and its
severity.
The cut-off UAA/Cr value of >1.14 has 84% sensitivity with a specificity of
94% and has a positive predictive value of 93.33% with a negative predictive
value of 85.45%.With an accuracy of 89%.

131

CONCLUSION
Perinatal asphyxia is a common neonatal problem and contributes significantly
to neonatal morbidity and mortality.
The signs of asphyxial injury are nonspecific and overlap with other illnesses.
In the absence of perinatal records, it is difficult to retrospectively diagnose
perinatal asphyxia.
Infants with asphyxia have higher urinary uric acid to creatinine ratio.It might
be used as an indicator for assessment of severity of birth asphyxia and post
asphyxia renal injuries in neonates.
There is a need to identify neonates who will be at high risk for HIE and early
neonatal death as a consequence of perinatal hypoxia.
EEG, cranial ultrasonography, CT, MRI, cerebral blood flow velocities,
somato-sensory evoked potentials and estimation of neurophysiological
markers such as CK-BB, brain specific LDH isomer, glutamate and neurone
specific enolase in the CSF are all useful in predicting both the immediate
dysfunction and the long term outcome. But none of these facilities are
routinely available except in few tertiary hospitals and in some of the teaching
hospitals of our country.
Large amounts of oxygen radicals that are produced in the
reoxygenation period,following asphyxia and it is expected that high levels of
uric acid are produced and excreted in the early part of first day of life.
Because urinary creatinine can be used as the reference substrate in a spot
132

urine sample, an increased UA/Cr ratio (as a sign of increased ATP

degradation) may be a valuable indicator of the severity of tissue hypoxia in
patients with intact renal functions. UA/Cr ratio estimation from spot urine
sample is available in most centres and are comparatively cheaper tests.
The cut-off UAA/Cr value of >1.14 has 84% sensitivity with a specificity of
94% and has a positive predictive value of 93.33% with a negative predictive
value of 85.45%.With an accuracy of 89%
So urinary uric acid to creatinine ratio can be used as an additional non-
invasive dis space,easy and at the same time early biochemical marker of
birth asphyxia which biochemically supports the clinical diagnosis and
severity grading of asphyxia by apgar score.
The predictive factors identified in this study should be examined for their
ability in a fresh clinical sample in the neonatal intensive care unit before
these markers can be applied on routine basis in a clinical scenario in infants
with perinatal asphyxia

133

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137) Ekin P, Toet M C, Groeneedaal F, et al. Predictive value of neuroimaging,

pulse Dopplerand neurophysiology in full term infants with hypoxic ischaemic
encephalopathy. Archives of Disease in Childhood 1995; 73: 75-80.
138) Bjerre , Hellstrom- Westas, Rosen , Swenningsen N. Monitoring of cerebral
function after severe asphyxia in infancy. Archives of Disease in Childhood
1983; 58: 997-1002.

145

ANNEXURE
PROFORMA OF THE DISSERTATION

STUDY OF URINARY URIC ACID/CREATININE RATIO AS A MARKER
OF NEONATAL ASPHYXIA IN A RURAL HOSPITAL

BABY OF: D.O.A-
SEX: D.O.D-
TIME AND DATE OF BIRTH:
BIRTH WEIGHT:

ASSESSMENT OF GESTATIONAL AGE:

METHOD LMP USG NEW BALLARD
SCORE
PERIOD OF
GESTATION


MATERNAL HISTORY:

NON STRESS TEST: REASSURING/ NON REASSURING

BIRTH NOTES:

THICK MECONIUM STAINED AMNIOTIC FLuID: YES/ NO

APGAR SCORE 1 MIN: 5 MIN: 10 MIN:

EXAMINATION OF THE BABY:

HEAD TO TOE EXAMINATION:

146

ANY OBVIOUS EXTERNAL CONGENITAL ABNORMALITIES:

NEUROLOGICAL EXAMINATION:

OTHER SYSTEMIC EXAMINATION:

COURSE IN NICU:

HIE STAGE:
INCLUSION CRITERIA YES NO
1) Gestational age 37 weeks
2) Appropriate for gestational age
3) The neonates will be identified to have
experienced perinatal asphyxia when at least 3
of the following are present:








A) Intrapartum signs of fetal distress, as indicated by late
decelerations on fetal monitoring or by thick meconium staining of
the amniotic fluid

B) APGAR score of <7 at one minute of life
C) RESUSCITATION with >1 minute of positive pressure
ventilation before stable spontaneous respiration.

D) Profound metabolic or mixed acidemia (pH<7.00) in an artery
blood sample, if obtained

E) Mild, moderate or severe hypoxic ischemic encephalopathy
(HIE), as defined by Sarnat & Sarnat, 1976


Exclusion criteria YES NO
1) Congenital malformations
2) Maternal drug addiction
3) Neonates born to mothers who would have received magnesium
sulphate within 4 hours prior to delivery or opiods (pharmacological

147

depression)
4) Congenital or acquired infections
5) Hemolytic disease of the newborn
6) Neonates born to mothers consuming alcohol
7) Neonates born to mothers who are smokers
8) Neonates born to mothers on anti epileptics.

investigations:
1) umbilical artery pH:

2)

markers levels in urine sample
a) uric acid
b) creatinine

3) urinary uric acid and creatinine ratio-
148

KEY TO MASTER CHART

SL.NO - SERIAL NUMBER
B/O - BABY OF
IP NO - IN-PATIENT NUMBER
M - MALE
F - FEMALE
GAA - GESTATIONAL AGE ASSESSMENT
T - TERM
PD - POST DATED
PT - POST TERM
BW - BIRTH WEIGHT
AGA - APPROPRIATE FOR GESTATIONAL AGE
MH - MATERNAL HISTORY
P - PRIMI
MG - MULTI GRAVIDA
MOD - MODE OF DELIVERY
ND - NORMAL DELIVERY
ID - INSTRUMENTAL DELIVERY
CS - CESAREAN SECTION
FD - FETAL DISTRESS
NST - NON STRESS TEST
R - REASSURING
NR - NON REASSURING
TMSAF - THICK MECONIUM STAINED AMNIOTIC FLUID (CASES)
MSAF - MECONIUM STAINED AMNIOTIC FLUID (CONTROLS)
149

APGAR - APGAR SCORE

1 - 1 MINUTE
5 - 5 MINUTES
10 - 10 MINUTES
RES - RESUSCITATION WITH >1 MINUTE OF POSITIVE
PRESSURE VENTILATION
ABG - ARTERIAL BLOOD GAS ANALYSIS-UMBILICAL ARTERY
NE - NEUROLOGICAL EXAMINATION
T - TONE
N - NORMAL
- HYPOTONIA
- HYPERTONIA
F - FLACCID
S - SEIZURE(S)
HIE - HYPOXIC ISCHEMIC ENCEPHALOPATHY (STAGES AS
DEFINED BY LEVENE MI)
1 - STAGE I-MILD
2 - STAGE II-MODERATE
3 - STAGE III-SEVERE
DAMA - DISCHARGE AGAINST MEDICAL ADVICE
UUA/CR - URINARY URIC ACID AND CREATININE RATIO

SL.NO NAME IPNO SEX GAA BW MH MOD APGAR RES ABG NE HIE D UUA/CR
NST TMSAF 1' 5' 10'
1 B/ONOORAISHA 7684 M PT 3.94kgAGA MG ND NR 1/10 8/10 8/10 + 7.28 TN,S 1 D 3.28
2 B/OSAVITHA 8970 M PD 2.60kgAGA P ND NR + 1/10 5/10 7/10 + 7.22 T,S+ 2 D 3.71
3 B/OPUNEETHA 8959 M T 2.58kgAGA P ND NR + 1/10 7/10 8/10 + 7.26 TN,S 1 DAMA 3.32
4 B/OUMADEVI 8171 F T 2.80kgAGA MG ND NR 5/10 8/10 8/10 + 7.29 TN,S 1 D 3.14
5 B/OKALPANA 8175 F T 2.53kgAGA MG CS NR + 1/10 5/10 6/10 + 7.14 TF,S+ 3 D 4.5
6 B/OSHOBA 8828 M T 2.66kgAGA P ND NR + 5/10 8/10 8/10 + 7.28 TN,S 1 D 3.38
7 B/OBHAGYAMMA 7444 M PD 2.60kgAGA MG ND NR 3/10 8/10 8/10 + 7.21 T,S+ 2 DAMA 3.82
8 B/OFATHIMA 6395 F T 2.98kgAGA P CS NR 4/10 9/10 9/10 + 7.29 TN,S 1 D 2.9
9 B/OSHILPA 6390 M T 2.84kgAGA MG CS NR + 3/10 8/10 8/10 + 7.26 TN,S 1 D 3.1
10 B/ODHANALAKSHMI 5149 M T 2.50kgAGA P ND NR 5/10 8/10 8/10 + 7.27 TN,S 1 D 3.06
11 B/ORADHA 17447 M T 2.70kgAGA MG CS NR 6/10 9/10 9/10 + 7.29 TN,S 1 D 3.14
12 B/OMANJULA 10245 M T 2.58kgAGA P ND NR 1/10 6/10 7/10 + 7.21 T,S+ 2 DAMA 2.45
13 B/OKUMARI 27038 F T 2.68kgAGA P CS NR 5/10 8/10 8/10 + 7.28 TN,S 1 D 1.92
14 B/OSHOBA 16712 F PD 3.78kgAGA MG ND NR 5/10 7/10 9/10 + 7.3 TN,S 1 D 3.02
15 B/OSHWETHA 16727 M PT 2.68kgAGA MG CS NR 2/10 8/10 8/10 + 7.25 TN,S 1 D 3.48
16 B/OSHYLA 10985 F T 3.00kgAGA MG CS NR 1/10 6/10 7/10 + 7.21 T,S+ 2 D 3.92
17 B/OSHWETHA 10883 F T 3.12kgAGA P ND R + 5/10 9/10 9/10 + 7.34 TN,S D 2.65
18 B/OAMBIKA 10673 F T 2.67kgAGA MG CS NR 1/10 8/10 8/10 + 7.23 T,S+ 2 D 2.88
19 B/ONETRAVATHI 9663 M T 3.52kgAGA P CS NR 3/10 8/10 9/10 + 7.45 TN,S D 2.54
20 B/OAKSHATA 9704 M T 2.64kgAGA P ND NR 1/10 4/10 6/10 + 7.16 TF,S+ 3 DAMA 4.22
21 B/OCHAITRA 9781 F T 3.05kgAGA P ID NR + 1/10 8/10 8/10 + 7.31 TN,S 1 D 2.12
22 B/OBHAGYA 10525 F T 2.63kgAGA P CS NR + 4/10 8/10 8/10 + 7.29 TN,S 1 D 1.78
23 B/OMANJULA 10566 M T 2.86kgAGA MG ND R 2/1O 4/10. 6/1O + 7.24 T,S+ 2 D 2.18
24 B/OPAVITRA 17179 M T 2.76kgAGA P ND NR + 6/10 8/10 8/10 + 7.32 TN,S D 1.53
25 B/OSUNITHA 26353 F T 2.67kgAGA MG CS NR 3/10 6/10 7/10 + 7.26 TN,S 1 D 2.1
26 B/ONEELAMMA 25177 M T 2.76kgAGA MG ND NR 4/10 6/10 8/10 + 7.19 T,S+ 2 D 2.98
27 B/OSHUBA 21360 M T 2.88kgAGA MG CS NR 5/10 6/10 7/10 + 7.3 TN,S D 1.02
28 B/OLAKSHMI 12361 M PD 2.61kgAGA P ND R 3/10 9/10 9/10 + 7.32 TN,S D 1.32
29 B/OSHAHEDA 24660 M T 2.77kgAGA MG ND NR + 3/10 6/10 7/10 + 7.22 T,S+ 2 D 2.93
30 B/OTEJAMANI 13886 F T 2.63kgAGA P ND NR 1/10 4/10 9/10 + 7.14 TF,S+ 3 D 3.72
31 B/OGANGAMMA 13946 M PD 3.0kgAGA P ND NR 5/10 9/10 9/10 + 7.35 TN,S D 1.2
32 B/OLEELAVATI 14271 F T 3.96kgAGA MG ND R 4/10 8/10 8/10 + 7.3 TN,S D 1.24
33 B/OGIRIJA 14732 M T 2.82kgAGA P CS NR + 1/10 8/10 8/10 + 7.28 TN,S 1 D 1.88
34 B/OMANJULA 14854 M PT 3.4kgAGA MG ND NR 1/10 4/10 6/10 + 7.2 T,S+ 2 D 2.84
35 B/OINDRAVENKATESH 14994 M PD 3.0kgAGA MG CS NR + 4/10 8/10 8/10 + 7.23 T,S+ 2 D 2.87
36 B/ORADHAMANI 11776 M PD 3.45kgAGA MG ID R + 4/10 8/10 8/10 + 7.32 TN,S D 1.32
37 B/ORATHNAMMA 5538 M PD 2.81kgAGA P ND NR + 1/10 3/10 6/10 + 7.14 TF,S+ 3 DAMA 4.18
38 B/OSHARADHA 5513 M T 3.05kgAGA MG ND NR + 2/10 5/10 7/10 + 7.24 T,S+ 2 D 2.48
39 B/OPREMA 5442 M PD 3.10kgAGA P ND R + 3/10 7/10 8/10 + 7.3 TN,S D 1.26
40 B/OMAHALAKSHMAMMA 5528 F PD 3.20kgAGA P ND NR 1/10 5/10 6/10 + 7.22 T,S+ 2 DAMA 2.38
41 B/OROOPA 19524 M T 2.75kgAGA P ND NR 4/10 7/10 9/10 + 7.42 TN,S D 0.82
42 B/OSHOBA 5291 F PD 3.0kgAGA P CS NR + 1/10 9/10 9/10 + 7.24 T,S+ 2 D 2.28
43 B/ODEVI 19271 M T 2.6kgAGA MG ND NR 1/10 4/10 6/10 + 7.22 T,S+ 2 D 2.88
44 B/OGIRIJA 27080 M T 3.50kgAGA P CS NR + 6/10 9/10 9/10 + 7.38 TN,S D 0.78
45 B/OSUMA 14137 F T 2.9kgAGA P ND NR + 3/10 9/10 9/10 + 7.36 TN,S D 0.98
46 B/OJYOTHI 14194 F PD 2.63kgAGA P CS NR 3/10 9/10 9/10 + 7.34 TN,S D 1.08
47 B/OPARVATHI 12625 F PD 3.1kgAGA P ID NR + 1/10 7/10 9/10 + 7.26 TN,S 1 D 1.62
48 B/OSAVITHA 12651 F T 2.6kgAGA P ND R + 4/10 7/10 8/10 + 7.33 TN,S D 1.12
49 B/OREVATHI 17831 M PT 3.2KGAGA P ID NR + 1/10 3/10 5/10 + 7.12 TF,S+ 3 DT 4.68
50 B/OSUSHMITA 17988 F PT 2.6KGAGA M ID NR + 1/10 3/10 5/10 + 7.1 TF,S+ 3 DT 4.94
FD
MasterChartofCases
SL.NO NAME IPNO SEX GAA BW MH MOD RES ABG NE UUA/CR
NST MSAF 1' 5' 10'
1 B/Ojyothi 27039 M T 2.5kgAGA P ND R 7/10 9/10 9/10 TN,S 0.76
2 B/Ovani 260973 M T 3.1kgAGA MG ND R 8/10 9/10 9/10 TN,S 0.82
3 B/Onalini 26960 M T 3.00kgAGA P ND R 7/10 9/10 9/10 TN,S 0.82
4 B/Osavithri 20642 F T 2.9kgAGA MG ND R 8/10 9/10 9/10 TN,S 0.98
5 B/Ovimala 20266 F T 3.25kgAGA P ND R 7/10 9/10 9/10 TN,S 0.65
6 B/Oroopa 16941 F T 2.65kgAGA P ND R 8/10 9/10 9/10 TN,S 0.98
7 B/Osuma 19596 M T 2.9kgAGA P ND R 7/10 9/10 9/10 TN,S 1.1
8 B/OSavitha 19147 M T 2.8kgAGA MG ND R 8/10 9/10 9/10 TN,S 0.9
9 B/OSharada 18797 M T 2.5kgAGA MG ND R 7/10 9/10 9/10 TN,S 0.64
10 B/Oprema 18236 M T 2.75kgAGA MG ND R 8/10 10/10 10/10 TN,S 0.42
11 B/OVaralakshmi 17708 F T 2.75kgAGA P ND R 7/10 9/10 9/10 TN,S 0.9
12 B/Oshalini 17550 M T 3.25kgAGA P ND R 8/10 9/10 9/10 TN,S 0.98
13 B/Orashmi 16665 M T 2.80kgAGA P ND R 7/10 9/10 9/10 TN,S 1.08
14 B/Omunjeba 17975 F T 2.75kgAGA P ND R 7/10 9/10 9/10 TN,S 0.82
15 B/Omanjula 16577 M T 2.75kgAGA MG ND R 8/10 10/10 10/10 TN,S 1.14
16 B/OShobha 7755 M T 2.6kgAGA MG ND R 8/10 9/10 9/10 TN,S 0.78
17 B/OPusphalatha 7742 F T 2.80kgAGA P CS R 7/10 9/10 9/10 TN,S 0.88
18 B/OShruthi 7676 F T 2.95kgAGA P ND R 8/10 9/10 9/10 TN,S 0.94
19 B/Opushpavathi 7602 F T 2.5kgAGA MG ND R 7/10 9/10 9/10 TN,S 0.99
20 B/Ouma 7589 M T 3.75kgAGA P ND R 8/10 9/10 9/10 TN,S 0.76
21 B/OBhagya 16278 F T 2.8kgAGA MG ND R 8/10 9/10 9/10 TN,S 0.68
22 B/Ochaithra 7840 M T 3.25kgAGA P ND R 7/10 9/10 9/10 TN,S 0.68
23 B/OShilpa 7803 M T 2.7kgAGA P ND R 7/10 9/10 9/10 TN,S 0.98
24 B/OLeelavathi 8294 F T 2.5kgAGA MG ND R 8/10 9/10 9/10 TN,S 0.92
25 B/Opavithra 8484 F T 2.8kgAGA P ND R 8/10 9/10 9/10 TN,S 0.52
26 B/Ovijayalakshmi 8541 M T 2.6kgAGA MG ND R 7/10 9/10 9/10 TN,S 1.04
27 B/Opushpa 9124 M T 3.5kgAGA MG ND R 8/10 10/10 10/10 TN,S 1.14
28 B/Osowbhagya 73062 F T 2.8kgAGA MG ND R 7/10 9/10 9/10 TN,S 0.62
29 B/Oroopa 76895 F T 3.25kgAGA P ND R 8/10 9/10 9/10 TN,S 0.64
30 B/Osavitha 27281 F T 3.6kgAGA P ND R 7/10 9/10 9/10 TN,S 0.88
31 B/Osowbhagya 75370 M T 2.75kgAGA MG ND R 7/10 9/10 9/10 TN,S 0.96
32 B/Odeepa 15882 F T 3.15kgAGA MG ND R 8/10 9/10 9/10 TN,S 1.14
33 B/OSuchitra 15972 M T 3.85kgAGA P ND R 7/10 9/10 9/10 TN,S 1.1
34 B/Ogeetha 16042 M T 3.00kgAGA MG ND R 8/10 9/10 9/10 TN,S 0.96
35 B/Ovani 14806 F T 3.50kgAGA P ND R 8/10 9/10 9/10 TN,S 0.92
36 B/Oshruthi 6481 F T 3.25kgAGA P ND R 7/10 9/10 9/10 TN,S 0.84
37 B/Opavithra 6979 F T 3.00kgAGA MG ND R 8/10 9/10 9/10 TN,S 1.02
38 B/OVaralakshmi 6893 F T 2.5kgAGA P ND R 8/10 9/10 9/10 TN,S 0.78
39 B/ORani 6856 F T 3.4kgAGA MG ND R 7/10 9/10 9/10 TN,S 0.76
40 B/OShakunthala 6854 M T 2.75kgAGA MG ND R 8/10 9/10 9/10 TN,S 0.74
41 B/Orahimabanu 6774 M T 3.15kgAGA P ND R 7/10 9/10 9/10 TN,S 0.98
42 B/Odhanalakshmi 6601 F T 3.5kgAGA P ND R 8/10 9/10 9/10 TN,S 0.68
43 B/Omamatha 6717 M T 3.05kgAGA P ND R 8/10 9/10 9/10 TN,S 0.92
44 B/ONoorasma 6526 M T 3.75kgAGA MG ND R 7/10 9/10 9/10 TN,S 0.68
45 B/ONagamma 6525 F T 3.6kgAGA MG ND R 8/10 9/10 9/10 TN,S 0.78
46 B/Odhanalakshmi 6445 M T 3.4kgAGA MG ND R 8/10 9/10 9/10 TN,S 0.92
47 B/OLakshmi 6442 F T 2.75kgAGA MG ND R 7/10 9/10 9/10 TN,S 1.02
48 B/OVaralakshmi 6043 F T 3.75kgAGA MG ND R 7/10 9/10 9/10 TN,S 1.04
49 B/OBhagya 6029 M T 3.20kgAGA P ND R 8/10 9/10 9/10 TN,S 0.62
50 B/OAsha 6039 F T 2.65kgAGA P ND R 8/10 9/10 9/10 TN,S 0.78
FD APGAR
MasterChartofControls