Yenidoğan Gözünden Hipoksik İskemik Ensefalopati
Özet
Hipoksik iskemik ensefalopati (HİE), plasental akımın bozulmasına bağlı olarak serebral kan akışının bozulması sonucu bilinç bozukluğu, hipotoni veya konvülsiyona yol açan heterojen klinik bulgularla seyreden bir durumdur. Görülme sıklığı 1000 canlı doğumda 2-9 arasındadır. Perinatal asfiksinin patofizyolojisindeki birincil olay, plasentadaki yetersiz gaz değişimi veya doğum sonrası olaylar nedeniyle pulmoner düzeyde ventilasyonun bozulmasıdır. HİE tanısı klinik ve laboratuvar bulguları ile değerlendirilir. Klinik bulguların ötesinde Sarnat ve Sarnat evrelemesi ve Thompson skoru özellikle takipte yaygın olarak kullanılmaktadır. Özellikle doğumhanede bu bebeklerde hiperoksi, hipokarbi, hipertermi ve hipoglisemiden kaçınılmalı ve yeterli ventilasyon sağlanmalıdır. Asfiktik olduğu düşünülen bebeklerde radyan ısıtıcılar kapatılarak resüsitasyona devam edilmelidir. Terapötik hipotermi, orta ila şiddetli hipoksik iskemik ensefalopatisi olan term ve yakın dönem bebeklerde etkinliği kanıtlanmış bir tedavidir. Bu nedenle hafif ve orta-şiddetli HİE ayrımı doğru yapılmalı ve tedaviye hızla başlanmalıdır. Yapılan çalışmalarda 18. ayın sonunda mortalite ve nörogelişimsel geriliğin belirgin olarak azaldığı gösterilmiştir. Aileye kraniyal görüntülemenin çok önemli olduğu vurgulanmalıdır.
Hypoxic ischaemic encephalopathy (HIE) is a condition with heterogeneous clinical findings leading to impaired consciousness, hypotonia or convulsion as a result of impaired cerebral blood flow due to impaired placental flow. The incidence is between 2-9 per 1000 live births. The primary event in the pathophysiology of perinatal asphyxia is impaired ventilation at the pulmonary level due to inadequate gas exchange in the placenta or postnatal events. The diagnosis of HIE is evaluated by clinical and laboratory findings. Beyond clinical findings, Sarnat and Sarnat staging and Thompson score are widely used especially in follow-up. Hyperoxia, hypocarbia, hyperthermia and hypoglycaemia should be avoided and adequate ventilation should be provided especially in the delivery room. In babies thought to be asphyctic, resuscitation should be continued by switching off radiant heaters. Therapeutic hypothermia is a treatment with proven efficacy in term and near-term infants with moderate to severe hypoxic ischaemic encephalopathy. Therefore, the distinction between mild and moderate-severe HIE should be made correctly and treatment should be started rapidly. Studies have shown that mortality and neurodevelopmental retardation decreased significantly at the end of the 18th month. The family should be emphasised that cranial imaging is very important.
Referanslar
Executive summary: Neonatal encephalopathy and neurologic outcome, second edition. Report of the American College of Obstetricians and Gynecologists’ Task Force on Neonatal Encephalopathy. Obstet Gynecol. 2014 Apr;123(4):896-901.
Molloy EJ, Branagan A, Hurley T, et al; Steering Group for DEFiNE (Definition of Neonatal Encephalopathy). Neonatal encephalopathy and hypoxic-ischemic encephalopathy: moving from controversy to consensus definitions and subclassification. Pediatr Res. 2023 Dec;94(6):1860-1863. doi: 10.1038/s41390-023-02775-z.
Türk Neonatoloji Derneği Hipoksik İskemik Ensefalopati Çalışma Grubu. Türkiye’de yenidoğan yoğun bakım ünitelerinde izlenen hipoksik iskemik ensefalopatili olgular, risk faktörleri, insidans ve kısa dönem prognozları. Çocuk Sağlığı ve Hastalıkları Dergisi 2008; 51:123-129.
Tan S, Wu Y, Nordli D, et al. Etiology and pathogenesis of neonatal encephalopathy. UpToDate, TW Post, ed (Waltham, MA). 2015.
Akisu M, Kumral A, Canpolat FE. Turkish Neonatal Society Guideline on neonatal encephalopathy. Turk Pediatri Ars. 2018 Dec 25;53(Suppl 1): S32-S44. doi: 10.5152/TurkPediatriArs.2018.01805.
Volpe JJ, Inder TE, Darras BT, et al. Volpe's Neurology of the Newborn: Elsevier Health Sciences; 2017.
Thompson CM, Puterman AS, Linley LL, et al. The value of a scoring system for hypoxic ischaemic encepha- lopathy in predicting neurodevelopmental outcome. Acta Paediatr 1997; 86:757-61
Okereafor A, Allsop J, Counsell SJ, et al. Patterns of brain injury in neonates exposed to perinatal sentinel events. Pediatrics 2008; 121:906
Papile LA, Baley JE, Benitz W, et al. Committee on Fetus and Newborn. Hypothermia and neonatal encephalopathy. Pediatrics 2014; 133:1146
Jacobs S.E, Berg M, Hunt R, et al: Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev 2013 Jan 31;(1): CD003311.
Wood T, Thoresen M. Physiological responses to hypothermia. Semin Fetal Neonatal Med. 2015 Apr;20(2):87-96.
Chalak LF, Nguyen KA, Prempunpong C, et al. Prospective research in infants with mild encephalopathy identified in the first six hours of life: neurodevelopmental outcomes at 18-22 months. Pediatr Res. 2018 Dec;84(6):861-868. doi: 10.1038/s41390-018-0174-x.
Finder M, Boylan GB, Twomey D, et al. Two-Year Neurodevelopmental Outcomes After Mild Hypoxic Ischemic Encephalopathy in the Era of Therapeutic Hypothermia. JAMA Pediatr. 2020 Jan 1;174(1):48-55. doi: 10.1001/jamapediatrics.2019.4011.
Lemmon ME, Barks MC, Bansal S, et al. The ALIGN Framework: A Parent-Informed Approach to Prognostic Communication for Infants With Neurologic Conditions. Neurology. 2023 Feb 21;100(8): e800-e807. doi: 10.1212/WNL.0000000000201600.
Referanslar
Executive summary: Neonatal encephalopathy and neurologic outcome, second edition. Report of the American College of Obstetricians and Gynecologists’ Task Force on Neonatal Encephalopathy. Obstet Gynecol. 2014 Apr;123(4):896-901.
Molloy EJ, Branagan A, Hurley T, et al; Steering Group for DEFiNE (Definition of Neonatal Encephalopathy). Neonatal encephalopathy and hypoxic-ischemic encephalopathy: moving from controversy to consensus definitions and subclassification. Pediatr Res. 2023 Dec;94(6):1860-1863. doi: 10.1038/s41390-023-02775-z.
Türk Neonatoloji Derneği Hipoksik İskemik Ensefalopati Çalışma Grubu. Türkiye’de yenidoğan yoğun bakım ünitelerinde izlenen hipoksik iskemik ensefalopatili olgular, risk faktörleri, insidans ve kısa dönem prognozları. Çocuk Sağlığı ve Hastalıkları Dergisi 2008; 51:123-129.
Tan S, Wu Y, Nordli D, et al. Etiology and pathogenesis of neonatal encephalopathy. UpToDate, TW Post, ed (Waltham, MA). 2015.
Akisu M, Kumral A, Canpolat FE. Turkish Neonatal Society Guideline on neonatal encephalopathy. Turk Pediatri Ars. 2018 Dec 25;53(Suppl 1): S32-S44. doi: 10.5152/TurkPediatriArs.2018.01805.
Volpe JJ, Inder TE, Darras BT, et al. Volpe's Neurology of the Newborn: Elsevier Health Sciences; 2017.
Thompson CM, Puterman AS, Linley LL, et al. The value of a scoring system for hypoxic ischaemic encepha- lopathy in predicting neurodevelopmental outcome. Acta Paediatr 1997; 86:757-61
Okereafor A, Allsop J, Counsell SJ, et al. Patterns of brain injury in neonates exposed to perinatal sentinel events. Pediatrics 2008; 121:906
Papile LA, Baley JE, Benitz W, et al. Committee on Fetus and Newborn. Hypothermia and neonatal encephalopathy. Pediatrics 2014; 133:1146
Jacobs S.E, Berg M, Hunt R, et al: Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev 2013 Jan 31;(1): CD003311.
Wood T, Thoresen M. Physiological responses to hypothermia. Semin Fetal Neonatal Med. 2015 Apr;20(2):87-96.
Chalak LF, Nguyen KA, Prempunpong C, et al. Prospective research in infants with mild encephalopathy identified in the first six hours of life: neurodevelopmental outcomes at 18-22 months. Pediatr Res. 2018 Dec;84(6):861-868. doi: 10.1038/s41390-018-0174-x.
Finder M, Boylan GB, Twomey D, et al. Two-Year Neurodevelopmental Outcomes After Mild Hypoxic Ischemic Encephalopathy in the Era of Therapeutic Hypothermia. JAMA Pediatr. 2020 Jan 1;174(1):48-55. doi: 10.1001/jamapediatrics.2019.4011.
Lemmon ME, Barks MC, Bansal S, et al. The ALIGN Framework: A Parent-Informed Approach to Prognostic Communication for Infants With Neurologic Conditions. Neurology. 2023 Feb 21;100(8): e800-e807. doi: 10.1212/WNL.0000000000201600.
