the correlation of clinical perinatal asphyxia with counts ... · counts of nrbc/100 wbc in cord...

Article ID: WMC001511 2046-1690

The Correlation Of Clinical Perinatal Asphyxia WithCounts Of Nrbc/100 Wbc In Cord BloodCorresponding Author:Dr. Geetika ,Assistant Professor, Obstetrics and Gynaecology, Subharti Medical College, 250001 - India

Submitting Author:Dr. Geetika Tomar,Assistant Professor, Obstetrics And Gynaecology, Subharti Medical College, 250001 - India

Article ID: WMC001511

Article Type: Original Articles

Submitted on:28-Jan-2011, 12:02:25 PM GMT Published on: 30-Jan-2011, 04:07:33 PM GMT

Article URL: http://www.webmedcentral.com/article_view/1511

Subject Categories:OBSTETRICS AND GYNAECOLOGY

Keywords:Birth Asphyxia, Apgar Score, Nucleated Red Blood Cells, Cord Blood pH

How to cite the article: G , Sikarwar S , Gupta S . The Correlation Of Clinical Perinatal Asphyxia With Counts OfNrbc/100 Wbc In Cord Blood . WebmedCentral OBSTETRICS AND GYNAECOLOGY 2011;2(1):WMC001511

Source(s) of Funding:

No funds required

Competing Interests:

No competing interests

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The Correlation Of Clinical Perinatal Asphyxia WithCounts Of Nrbc/100 Wbc In Cord BloodAuthor(s): G , Sikarwar S , Gupta S

Abstract

Objective: To study the correlation of clinical perinatalasphyxia with counts of nRBC/100 WBC in cord blood.Method: This is a prospective comparative studyconducted from July 2008 to June 2009. It comprisedof two groups, cases and controls. The case groupconsisted of 50 newborns with perinatal asphyxia andthe control group had 50 non asphyxiated newborns.The cord blood was collected immediately after birthfor Hb%, TLC, pH and nRBC/100WBC countdetermination. Early neonatal outcome of both thegroups was also evaluated. Statistical analysis wasdone using SPSS software and application of chisquare and Pearson’s correlation (sigma 2-tailed) tests.Results: The mean nRBC/100 WBC count for controlgroup was 5.7 (+2.33212) and for case group was10.34 (+3.87883). This difference was statisticallysignificant (pConclusion: The nRBC/100 WBC count correlates wellwith perinatal asphyxia and associated early neonataloutcome.

Introduction

Perinatal asphyxia still remains a significant cause ofperinatal mortality and is known to complicate 5-10%of all deliveries. There is no universally accepteddefinition of asphyxia, a term that should beexclusively used to indicate those infants who havemetabolic acidosis and hypoxia at birth. Recentlyevidence has been accumulating rapidly that FHR(fetal heart rate) changes and blood acid base statusof the fetus /neonate and Apgar scores are very poorpredictors of long term outcome. It is now beingsuggested that birth asphyxia should only bediagnosed when the baby goes on to develop HIEwhich has shown to be a much more reliable indicatorof long term handicap than any other perinatalmarkers. In situations where facilities for cord bloodanalysis are not available it would be very useful tohave another surrogate marker for fetal asphyxia.Considering the hematopoietic response to hypoxiainutero the elevated nRBC/100 WBC count is being

hailed as the marker for not only perinatal asphyxiabut also the chances of the neonate to go on todeveloping neurological sequelae[1].The present study was undertaken to assess thenRBC /100 WBC count as a marker of perinatalasphyxia in conjunction with other clinical markers andits ability to predict immediate neonatal prognosis incases of asphyxia.

Method

This prospective comparative study was conductedfrom July 2008 to June 2009. It included 50 womeneach in case and control groups who were in labourbetween 38 and 42 weeks of gestation with termsingleton pregnancies. They were observed duringlabour for development of signs of irregular FHS,meconium staining of liquor, APGAR at 1 min < 6 andumbilical cord arterial blood pH < 7.1 were taken ascase group. For the control group the criteria werereassuring FHS pattern , clear liquor , APGAR at 1min> 6 and pH >7.1 .Pregnancies associated withelevated nRBC count in fetal/ neonatal blood , Rhisoimmunisation , maternal anemia , diabetes mellitus, multiple pregnancy and preterm deliveries wereexcluded from the study. Immediately after the birth ofthe placenta , 1 ml of blood was collected in a preheparinised syringe from a doubly clamped segmentof the umbilical cord for pH estimation by Combilineanalyser and another 2 ml was collected in an EDTAvial from which haemoglobin , total leucocyte countand a thin blood film was prepared .The film wasstained by Leishman’s stain and nRBC / 100 WBCwere counted at 40X magnification .The data wasanalysed using SPSS 11.5 software and chi square orPearson’s correlation ( sigma 2 tailed) were applied asappropriate.

Observation and Discussion

Both the case and control groups were comparable interms of maternal age, parity, period of gestation, birthweight and sex of the neonate (Table 1). The meannRBC/100 WBC count for case group was10.3400+3.87883 and for the control group was5.7000+2.33212. This difference was highly significant



(p Previous authors have concluded that intra uterinehypoxia causes release of erythropoietin leading toincreased mitosis of erythroid precursors and theirrelease in the fetal circulation. This holds true for bothacute as well as chronic hypoxia though the exactmechanism of increased peripheral NRBC still remainselusive.Fanaroff (2) concluded that normoblasts could enterthe bloodstream within 30 minutes of a severe hypoxicinjury. Korst et al (3) and Phelan et al (4) foundincreased nRBCs after acute catastrophic intrapartumevents. The duration of these catastrophic events wasundoubtedly less than one hour in most cases.Although it is now reasonable to conclude that it is lessthan 60 minutes and perhaps as short as 20-30minutes. Phelan et el(4) found the mean nRBC/100WBC count of 3.4+3.0 in non asphyxiated neonatesand the count was 34.5+6.83 in asphyxiated neonates. In this study the mean nRBC /100 WBC count incases of perinatal asphyxia was 10.34+3.88 incomparison the mean value for controls was 5.7+2.33.Spencer et al (5) have observed that nRBC count is abetter marker of fetal metabolic acidosis than MSAF,non reassur ing FHR, low APGAR scores.Hanon-Lundberg and Kirby (6) found that nRBCcounts increased with progressive increase in cordacidosis and progressive decreases in APGAR scores.In this study a very strong and negative correlationwas present between nRBC values and APGARscores at 1 min and umbilical artery pH.Bunocore et al (7), Ghosh et al (8) and Ferns et al (9)concluded that nRBC count at birth not only reflects ahaematological response of infant to perinatalasphyxia but is also a reliable marker of perinatal braindamage .This study shows a very strong significancebetween nRBC counts of group with early neonatalmortality and group without neonatal mortality (p)

Conclusion

The clinical diagnosis of perinatal asphyxia is basedon several criteria, the two main ones being evidenceof cardiorespiratory and neurological depression(defined as an Apgar score remaining less than 7 at 5minutes after birth) and evidence of acute hypoxiccompromise with acidaemia (defined as an arterialblood pH of less than 7.1 or base excess greater than12 mmol/L). In many sett ings, especial lyresource-poor countries, it may be impossible toassess fetal or neonatal acidaemia. Hence nRBCcount can be a useful part of the obstetrician’sarmamentarium for the evaluation of perinatalasphyxia where facilities of pH sampling are not

available and can serve as are liable, inexpensive andeasily available marker of perinatal asphyxia.

References

1. Saracoglu F, Sahin I, Eser E, et al. Nucleated redblood cell as a marker of fetal hypoxia. International JObstetric and Gynecology 2000; 71:113-8.2. Jones G, Steketee RW, Black RE, et al. How manychild deaths can we prevent this year? Lancet 2003;362:65–71. 3. Korst LM, Phelan JP, Ahn MO, et al. Nucleated redblood cells: An update on the marker for fetal asphyxia.Am J Obstet Gynecol 1996; 175:843-846.4. Phelan JP, Korst LM, Ahn MO, et al. Neonatalnucleated red blood cell and lymphocyte counts infetal brain injury. Obstet Gynecol 1998; 91:485-489.5. Blackwell SC, Refuerzo JS, Wolfe HM, et al. Therelationship between nucleated red blood cell countsand early-onset neonatal seizures. Am J ObstetGynecol 2000; 182:1452-1457.6. Hanlon-Lundberg KM, Kirby RS. Nucleated redblood cells as a marker of acidemia in term neonates.Am J Obstet Gynecol 1999; 181:196-201.7. Buonocore G, Perrone S, Gioia D, et al. Nucleatedred blood cell count at birth as an index of perinatalbrain damage. Am J Obstet Gynecol 1999;181:1500-1505.8. Ghosh B, Mittal S, Kumar S, Dadhwal V. Predictionof perinatal asphyxia with nucleated red blood cells incord blood of newborns. International Journal ofGynecology and Obstetrics 2003; 8:267-71.9. Ferns SJ, Bhat BV, Basu D. Value of nucleated redblood cells in predicting severity and outcome ofperinatal asphyxia Indian J Pathol Microbiol 2004 Oct;47(4):503-5.


http://clinicalevidence.bmj.com/ceweb/conditions/chd/0320/0320_G1.jsp


Characteristics Cases Controls p value

Maternal age 23.96+3.44 23.88+3.28 p>0.05

mean(+SD) in yrs

Parity p>0.05

Primigravida 24(48%) 17 (34%)

Multigravida 26(52%) 33 (66%)

Period of gestation p>0.05

mean(+SD) in wks 38.86+1.29 38.76+1.00

Mode of delivery p<0.001

Vaginal 24(46%) 41(92%)

LSCS 26(52%) 09(18%)

Sex of neonate p>0.05

Male 23(46%) 25(50%)

Female 27(54%) 25(50%)

Birth weight p>0.05

mean(+SD) in kgs 2.55+0.21 2.49+0.23

Illustrations

Illustration 1

Characteristics of mothers and newborns in the study group



Group Mean Std. Deviation N

Cases 10.3400 3.87883 50

Controls 5.7000 2.33212 50

Total 8.0200 3.94656 100

t = 3.95

p < 0.0001( highly significant)

Illustration 2

Comparison of nRBC /100 WBC count values



nRBC 100 WBC pH

nRBC 100 WBC Pearson Correlation 1 -.365(**)

Sig. (2-tailed) . .009

N 50 50

pH Pearson Correlation -.365(**) 1

Sig. (2-tailed) .009 .

N 50 50

** Correlation is significant at the 0.01 level (2-tailed).

Illustration 3

Correlation between nRBC counts and pH in cases



nRBC 100

WBC

APGAR 1

nRBC /100 WBC counts Pearson Correlation 1 -.321(*)

Sig. (2-tailed) . .023

N 50 50

APGAR 1 Pearson Correlation -.321(*) 1

Sig. (2-tailed) .023 .

N 50 50

* Correlation is significant at the 0.05 level (2-tailed).

Illustration 4

Correlations between nRBC counts and APGAR 1min in cases



Early neonatal death Mean Std. Deviation N

No 7.7234 3.825239 4

Yes 12.6667 2.94392 6

Total 8.0200 3.94656 100

t = 3.91

p <0.0001 (highly significant)

Illustration 5

Comparison of nRBC/ 100WBC count values in relation to early neonatal death



DisclaimerThis article has been downloaded from WebmedCentral. With our unique author driven post publication peerreview, contents posted on this web portal do not undergo any prepublication peer or editorial review. It iscompletely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscriptbut also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions beforesubmitting any information that requires obtaining a consent or approval from a third party. Authors should alsoensure not to submit any information which they do not have the copyright of or of which they have transferredthe copyrights to a third party.

Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater tothe needs of an individual patient. The web portal or any content(s) therein is neither designed to support, norreplace, the relationship that exists between a patient/site visitor and his/her physician. Your use of theWebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harmthat you may suffer or inflict on a third person by following the contents of this website.



Reviews

Review 1

Review Title: The Correlation of Clinical Perinatal Asphyxia With Counts OfNrbc In Cord BloodPosted by Dr. Ujjwal K Ghosh on 15 Feb 2011 03:27:00 AM GMT

1 Is the subject of the article within the scope of the subject category? Yes

2 Are the interpretations / conclusions sound and justified by the data? Yes

3 Is this a new and original contribution? No

4 Does this paper exemplify an awareness of other research on the topic? Yes

5 Are structure and length satisfactory? Yes

6 Can you suggest brief additions or amendments or an introductory statement that will increasethe value of this paper for an international audience?

Yes

7 Can you suggest any reductions in the paper, or deletions of parts? No

8 Is the quality of the diction satisfactory? Yes

9 Are the illustrations and tables necessary and acceptable? Yes

10 Are the references adequate and are they all necessary? Yes

11 Are the keywords and abstract or summary informative? Yes

Rating: 6

Comment: Inclusion of all the cases irrespective nrbc value would have enabled a better understanding and betterinterpretation of the results. A larger randomised study would be a more appropriate design of the study

Competing interests: no

Invited by the author to make a review on this article? : Yes

Experience and credentials in the specific area of science: 35 years

Publications in the same or a related area of science: No

How to cite: Ghosh U.The Correlation of Clinical Perinatal Asphyxia With Counts Of Nrbc In Cord Blood[Reviewof the article 'The Correlation Of Clinical Perinatal Asphyxia With Counts Of Nrbc/100 Wbc In Cord Blood ' by].WebmedCentral 1970;2(2):REVIEW_REF_NUM472


http://http://www.webmedcentral.com/Article_Review_View/472



Review 2

Review Title: Good preliminary dataPosted by Ms. Judy S Cohain on 13 Feb 2011 11:13:22 AM GMT



3 Is this a new and original contribution? Yes




Yes






Rating: 5

Comment: "Perinatal asphyxia complicates 5-10% of births" probably only applies to settings where induction andaugmentation with pitocin, vacuum and epidural and general anesthesia for cesarean are used in the majority ofbirths. In my practice of low and medium risk homebirths, none with Apgar under 7 at 5 minutes.

Sample was collected after delivery of the placenta, but it is not mentioned when that was. How was theplacenta delivered and how many minutes after delivery of the baby. In my experience, it is more accurate tosample the blood from the cord immediately following birth, BEFORE delivery of the placenta.

The article is complete as stands, but it always interests me to get more details on the 6 ? babies who died in thefirst week. Illlustration 5 is hard for me to understand the N column. Yes=6, no= 4 and Total= 100?

Competing interests: none

Invited by the author to make a review on this article? : No

Experience and credentials in the specific area of science: private practice births


How to cite: Cohain J.Good preliminary data[Review of the article 'The Correlation Of Clinical Perinatal AsphyxiaWith Counts Of Nrbc/100 Wbc In Cord Blood ' by ].WebmedCentral 1970;2(2):REVIEW_REF_NUM466




Review 3

Review Title: Good preliminary dataPosted by Ms. Judy S Cohain on 13 Feb 2011 11:13:21 AM GMT



3 Is this a new and original contribution? Yes




Yes






Rating: 5

Comment: "Perinatal asphyxia complicates 5-10% of births" probably only applies to settings where induction andaugmentation with pitocin, vacuum and epidural and general anesthesia for cesarean are used in the majority ofbirths. In my practice of low and medium risk homebirths, none with Apgar under 7 at 5 minutes.

Sample was collected after delivery of the placenta, but it is not mentioned when that was. How was theplacenta delivered and how many minutes after delivery of the baby. In my experience, it is more accurate tosample the blood from the cord immediately following birth, BEFORE delivery of the placenta.

The article is complete as stands, but it always interests me to get more details on the 6 ? babies who died in thefirst week. Illlustration 5 is hard for me to understand the N column. Yes=6, no= 4 and Total= 100?

Competing interests: none

Invited by the author to make a review on this article? : No

Experience and credentials in the specific area of science: private practice births


How to cite: Cohain J.Good preliminary data[Review of the article 'The Correlation Of Clinical Perinatal AsphyxiaWith Counts Of Nrbc/100 Wbc In Cord Blood ' by ].WebmedCentral 1970;2(2):REVIEW_REF_NUM465




DisclaimerThis article has been downloaded from WebmedCentral. With our unique author driven post publication peerreview, contents posted on this web portal do not undergo any prepublication peer or editorial review. It iscompletely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscriptbut also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions beforesubmitting any information that requires obtaining a consent or approval from a third party. Authors should alsoensure not to submit any information which they do not have the copyright of or of which they have transferredthe copyrights to a third party.

Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater tothe needs of an individual patient. The web portal or any content(s) therein is neither designed to support, norreplace, the relationship that exists between a patient/site visitor and his/her physician. Your use of theWebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harmthat you may suffer or inflict on a third person by following the contents of this website.


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