THEORY QUESTIONS Model answers What is birth asphyxia

THEORY QUESTIONS Model answers

What is birth asphyxia? What are the preventive steps to avoid birth asphyxia in growth restricted babies? Enumerate the long term effects of birth asphyxia. (2 +4+4).

What is birth asphyxia? AAP, ACOG, ITCP u Umbilical artery metabolic or mixed respiratorymetabolic acidemia with p. H less than 7. 00 u A persistent Apgar score of 0 to 3 for more than 5 minutes u. Neonatal neurological sequelae, such as seizures, coma or hypotonia (neonatal encephalopathy) u. Multiorgan system dysfunction

Current definition (WHO ICD-10) • P 21. 0 Severe birth asphyxia • Pulse less than 100 per minute at birth and falling or steady, respiration absent or gasping, colour poor, tone absent. • Asphyxia with 1 -minute Apgar score 0 -3 White asphyxia • P 21. 1 Mild and moderate birth asphyxia • Normal respiration not established within one minute, but heart rate 100 or above, some muscle tone present, some response to stimulation. • Asphyxia with 1 -minute Apgar score 4 -7 Blue asphyxia

Other WHO Definition Birth asphyxia is defined as the failure to initiate and sustain breathing at birth

Preventive steps to avoid birth asphyxia in growth restricted babies Identify • IUGR fetuses whose health is endangered in utero because of a hostile intrauterine environment • Monitor Intervene appropriately • Identify small but healthy fetuses and avoiding iatrogenic harm to them

Stage based Classification and management of FGR

System Dysfunction CNS Hypoxic ischemic encephalopathy, intracranial hemorrhage seizures, long-term neurological sequelae Cardiac Myocardial dysfunction, valvular dysfunction, rhythm abnormalities, congestive cardiac failure Renal Hematuria, acute tubular necrosis, renal vein thrombosis Metabolic Acidosis, hypoglycemia, hypocalcemia, hyponatremia Pulmonary Delayed adaptation, respiratory failure, meconium aspiration Surfactant depletion, primary pulmonary hypertension GI Tract Necrotizing enterocolitis, hepatic dysfunction Hematological Thrombocytopenia, coagulation abnormalities

• Enumerate various types of scientific studies and their role in establishing levels of evidence and recommendations for clinical practice (10 marks) •

Case series or Case reports • Collections of reports on the presentation / treatment of patients or a report on a single patient. • They are just reports and there are no control groups • No statistical validity • For Eg: Unusual presentation of Cancer Cervix

Case Control studies • Studies in which patients who already have a specific condition are compared with people who do not have the condition. • Based on medical records and patient recall for data collection. • Less reliable than RCTs and Cohort studies because showing a statistical relationship does not mean than one factor necessarily caused the other. • Eg: Demonstration of the link between tobacco smoking and lung cancer, by Richard Doll and Bradford Hill. • They showed a statistically significant association in a large casecontrol study.

Cohort Studies • Identify a group of patients who are already taking a particular treatment or have an exposure, follow them forward over time, and then compare their outcomes with a similar group that has not been affected by the treatment or exposure being studied. • Observational studies • Not reliable as RCTs • Nichol, K. L. , Nordin, J. D. , Nelson, D. B. , Mullooly, J. P. , & Hak, E. (2007). Effectiveness of influenza vaccine in the communitydwelling elderly. New England Journal of Medicine, 357(14), 13731381. • To determine the long-term effectiveness of influenza vaccines in elderly people, cohorts of vaccinated elderly and unvaccinated community-dwelling elderly were studied. The results suggest that the elderly who are vaccinated have a reduced risk of hospitalization for pneumonia or influenza.

Randomized Controlled Trials • A study in which people are allocated at random (by chance alone) to receive one of several clinical interventions. One of these interventions is the standard of comparison or control. The control may be a standard practice, a placebo ("sugar pill"), or no intervention at all. • Advantages • Good randomization will “wash out” any population bias • Easier to blind/mask than observational studies • Disadvantages • Expensive in terms of time and money • Volunteer biases: the population that participates may not be representative of the whole • Does not reveal causation • Loss to follow-up attributed to treatment

Randomized Control Trial • Ensrud, K. E. , Stock, J. L. , Barrett-Connor, E. , Grady, D. , Mosca, L. , Khaw, K. , et al. (2008). Effects of raloxifene on fracture risk in postmenopausal women: The raloxifene use for the heart trial. Journal of Bone and Mineral Research, 23(1), 112 -120. • This research studied the effect of raloxifene on fracture risk in postmenopausal women, and found that the women who took raloxifene over the same five year period of time as the women who did not reduced their risk of clinical vertebrate fracture.

Systematic Review • is a type of literature review that collects and critically analyzes multiple research studies or papers. A review of existing studies is often quicker and cheaper than embarking on a new study. • Cochrane Review • Advantages • Less costly to review prior studies than to create a new study • Less time required than conducting a new study • Results can be generalized and extrapolated into the general population more broadly than individual studies • Eg: Early skin-to-skin contact for mothers and their healthy newborn infants 2012

Meta analysis • a method for systematically combining pertinent qualitative and quantitative study data from several selected studies to develop a single conclusion that has greater statistical power. This conclusion is statistically stronger than the analysis of any single study, due to increased numbers of subjects, greater diversity among subjects, or accumulated effects and results. • Bahekar, A. A. (2007). The prevalence and incidence of coronary heart disease is significantly increased in periodontitis: A meta-analysis. American Heart Journal, 154(5), 830 -7. • Previous studies have shown conflicting results as to whether periodontitis (PD) is associated with increased risk of coronary heart disease. Meta-analysis of the 5 prospective cohort studies (86, 092 patients) indicated that individuals with PD had a 1. 14 times higher risk of developing CHD than the controls (relative risk 1. 14, 95% CI 1. 074 -1. 213, P < . 001), indicating that both the prevalence and incidence of CHD are significantly increased in PD and PD may be a risk factor for CHD.

• Evidence-based medicine (EBM), is about finding evidence and using that evidence to make clinical decisions. A cornerstone of EBM is the hierarchical system of classifying evidence. This hierarchy is known as the levels of evidence.

Levels of Evidence • A ranking system used to describe the strength of the results measured in a Scientific study • The design of the study – Case Report / Double blind trial • The endpoints measured (such as survival/ quality of life) affect the strength of the evidence

Grades of Recommendation A Directly based on Level I evidence B Directly based on Level II evidence or extrapolated recommendations from Level I evidence C Directly based on Level III evidence or extrapolated recommendations from Level I or II evidence D Directly based on Level IV evidence or extrapolated recommendations from Level I, II, or III evidence

Practice Guideline • A statement produced by a panel of experts that outlines current best practice to inform health care professionals and patients in making clinical decisions. The statement is produced after an extensive review of the literature and is typically created by professional associations, government agencies, and/or public or private organizations. • Eg: NICE Guidelines