CLINICOETIOLOGICAL PROFILE OF RESPIRATORY DISTRESS IN NEONATES.
Respiratory distress is one of the most common disorders encountered within the first 48-72 hours of life and is a major cause for the leading morbidity in newborn, especially in preterm neonates. Respiratory distress occurs approximately in 7 percent of neonates and preparation is crucial for physicians providing neonatal care. 
In the last 3 decades several improvements have been introduced to reduce the incidence, severity and mortality of neonatal respiratory distress. Among these milestones are the induction of lung maturation with antenatal steroids, centralization of high-risk pregnancies to tertiary perinatal centres, usage of surfactant to treat immature lungs and introduction of new methods of mechanical ventilation and the use of nasal CPAP. 
MATERIALS AND METHODS
Source of Data
This study was a cross sectional descriptive study conducted by observation of neonates admitted with respiratory distress to the NICU of Cheluvamba hospital attached to Mysore Medical College from January 2015 to June 2016.
Cross sectional descriptive study.
Neonates born in Cheluvamba hospital with presence of at least 2 of the following criteria--
* Tachypnoea (RR> 60 per min)
* Subcostal or intercostals recessions
* Expiratory grunting/groaning 
* Neonates with respiratory distress who were born outside our hospital and was referred to us for management of respiratory distress. 
* Babies born in our hospital but developing respiratory distress after 28 days of Life. 
Majority of mothers whose newborns developed respiratory distress were primi mothers 60.8% (152 cases). Majority of cases of MAS, birth asphyxia and pneumonia were seen in primi mothers.
There were total 11 cases whose mothers had history of gestational diabetes out of which 7 were preterms and 4 were term babies. 6 out of 7 preterms developed HMD (6 cases). All term babies and 1 late preterm developed TTNB (5 cases).
Among the various aetiologies majority of cases were meconium aspiration syndrome 78 cases (31.2%) followed by hyaline membrane disease 65 cases (26%).
Among the non-respiratory causes majority aetiology were birth asphyxia 26 cases (10.4%).
Out of 65 cases of HMD majority 93.85% (61 out of 65) were cases who have not received antenatal steroids.
Only 18 cases (7.2%) had history of prolonged rupture of membranes of which 11 cases (61.11%) had culture positive sepsis. 6 cases of HMD, 6 cases of MAS, 4 cases of pneumonia, 1 TTNB, 1 Birth asphyxia.
Immediate Outcome of Respiratory Distress
The neonates admitted with respiratory distress in our NICU had a survival rate of 75.2% (188 out of 250). Majority of neonates who expired were due to hyaline membrane disease. 53.3% (33 out of 62 cases).
In the present study, majority of cases of respiratory distress were due to meconium aspiration syndrome followed by hyaline membrane disease. In the study by Clark et al,  the majority of cases were hyaline membrane disease followed by meconium aspiration syndrome. Dutta et al  and Kumar et al  in their study had a highest incidence of transient tachypnoea of newborn. Mathur et al  had pneumonia as the majority of cases. The highest incidence of meconium aspiration syndrome in the present study is probably due to majority of cases of high risk pregnancies being referred to our hospital from the periphery for management and lack of adequate infrastructure to manage the large number of deliveries in our hospital which results in delay in early identification of fetal compromise and timely interventions like elective caesarean section in the presence of risk factors.
In all studies there has been a male predilection for development of respiratory distress the cause of which is unknown. In our study the Male: Female ratio of 1.3:1 which was statistically significant (p=0.023), was similar to that observed by Rubatelli et al. 
In the present study, majority of the study population were of birth weight above 2.5 kg, followed by low birth weight neonates. Similar observations were made by Li-ling et al  in 23 NICUs in tertiary maternity and children's hospitals from major cities in China.
In the present study majority of neonates admitted with respiratory distress were term neonates. Similar observations were also made by Dutta et al  in their study among Italian infants born in 65 hospitals in Italy in 1996 and Abdelrahman et al in the NICU of Omdurman Maternity Hospital, Sudan in 2013.
In the present study all cases of respiratory distress among neonates of diabetic mothers were either hyaline membrane disease or transient tachypnoea of newborn. Similar observations were also made by Rubetelli et al and by Li-ling et al.
In the present study the majority of cases of respiratory distress among neonates whose mothers had pre-eclampsia were hyaline membrane disease followed by meconium aspiration syndrome. In the study by Li-ling et al. Majority of cases were hyaline membrane disease followed by pneumonia. The higher incidence of hyaline membrane disease is probably due to the increased chance of preterm births in case of maternal severe pre-eclampsia for which termination of pregnancy is indicated in view of maternal benefits.
In the present study, 93.85% cases of hyaline membrane disease have not received antenatal steroids whereas in the study by Dani et al  only 25.07% cases of hyaline membrane disease have not received antenatal steroids. In the present study, we had 101 cases with history of meconium stained amniotic fluid out of which 77.2% cases developed meconium aspiration syndrome. This was much higher percentage as compared to the observations by Ashtekar et al.  In our present study, 7.2% cases had history of prolonged rupture of membranes. This observation was comparable to that made by the study conducted by Rubatelli et al. (5.2%).
In the present study majority of cases of respiratory distress were born of normal vaginal delivery followed by emergency caesarean section. Similar observations were also made by Levine et al  and Liu et al. 
In the present study the case fatality rate of hyaline membrane disease was found to be the highest (50.8%). Similar studies also had hyaline membrane disease with the highest case fatality rate. Case fatality rate of meconium aspiration syndrome was found to be 11.5% and that of pneumonia was found to be 20% which was similar to that observed by Rubetelli et al.
Meconium aspiration syndrome is the most common cause of respiratory distress among neonates born in Cheluvamba hospital followed by hyaline membrane disease. Neonatal respiratory distress had a male predilection. Maternal risk factors which were significant were primi parity, gestational diabetes, pre-eclampsia, multiple gestation, not receiving antenatal steroids in preterm labour. Intrapartum risk factors like prolonged labour, meconium stained amniotic fluid, mode of delivery, and low Apgar scores at birth also affect the aetiology of respiratory distress in neonates. Mortality among the neonates with respiratory distress was 24.8%. The highest case fatality rate is for hyaline membrane disease 50.8%.
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Reshmi (1), Manjunatha (2), Sagar Bharamakkanavar (3)
(1) Senior Resident, Department of Paediatrics, Christian Medical College, Vellore, Tamilnadu, India.
(2) Associate Professor, Department of Paediatrics, Cheluvamba Hospital, MMC&RI, Mysore, Karnataka, India.
(3) Resident, Department of Paediatrics, Cheluvamba Hospital, MMC&RI, Mysore, Karnataka, India.
'Financial or Other Competing Interest': None.
Submission 23-01-2019, Peer Review 07-03-2019, Acceptance 13-03-2019, Published 25-03-2019.
Corresponding Author: Dr. Manjunatha, Associate Professor, Department of Paediatrics, Cheluvambha Hospital, MMC&RI, Mysore-570001, Karnataka, India.
Table 1. Respiratory Causes Diagnosis No. of Cases Percentage Meconium Aspiration Syndrome 78 31.2% Hyaline Membrane Disease 65 26% Transient Tachypnoea 50 20% Pneumonia 25 10% Right Pulmonary Aplasia 1 0.4% Table 2. Non-Respiratory Causes Diagnosis Cases Percentage Birth Asphyxia 26 10.4% Congenital Diaphragmatic Hernia 3 1.2% Tracheo-Oesophageal Fistula 2 0.8% Congenital Heart Disease 1 0.4% Pierre Robin Sequence 1 0.4% Table 3. Gestational Age Wise Distribution of Aetiology of Respiratory Distress Preterm Diagnosis SGA AGA LGA Meconium Aspiration Syndrome 20.8% 52% 10.4% Hyaline Membrane Disease 83.2% 57 22.8% 0 Transient Tachypnoea 10.4% 13 5.2% 10.4% Pneumonia 0 4 1.6% 20.8% Birth Asphyxia 0 6 2.4% 0 Right Pulmonary Aplasia 0 0 0 Congenital Diaphragmatic Hernia 10.4% 0 0 Tracheo Oesophageal Fistula 0 0 0 Congenital Heart Disease 0 0 0 Pierre Robin Sequence 0 0 0 Term Diagnosis SGA AGA LGA Meconium Aspiration Syndrome 10 4% 57 22.8% 0 Hyaline Membrane Disease 93.6% 0 0 Transient Tachypnoea 0 24 9.6% 2 0.8% Pneumonia 20.8% 17 6.8% 0 Birth Asphyxia 0 17 6.8% 0 Right Pulmonary Aplasia 0 1 0.4% 0 Congenital Diaphragmatic Hernia 10.4% 1 0.4% 0 Tracheo Oesophageal Fistula 10.4% 1 0.4% 0 Congenital Heart Disease 0 1 0.4% 0 Pierre Robin Sequence 0 1 0.4% 0 Post Term Diagnosis SGA AGA LGA Meconium Aspiration Syndrome 2 0.8% 20.8% 0 Hyaline Membrane Disease 0 0 0 Transient Tachypnoea 0 0 0 Pneumonia 0 0 0 Birth Asphyxia 0 10.4% 0 Right Pulmonary Aplasia 0 0 0 Congenital Diaphragmatic Hernia 0 0 0 Tracheo Oesophageal Fistula 0 0 0 Congenital Heart Disease 0 0 0 Pierre Robin Sequence 0 0 0 Table 4. Maternal Parity Versus Aetiology of Respiratory Distress (p = 0.005) Diagnosis Primipara Multipara MAS 51 27 HMD 32 33 TTNB 30 20 Pneumonia 17 8 Birth Asphyxia 21 3 CDH 0 3 TEF 0 2 Congenital Heart Disease 0 1 Right Pulmonary Agenesis 1 0 Pierre Robin Sequence 0 1 Figure 1. Aetiology of Respiratory Distress in Neonates of Diabetic Mothers 5 P value = 0.006 TTNB HMD PRETERM 6 1 TERM 4 Note: Table made from bar graph. Figure 2. Hyaline Membrane Disease Cases Not Received Antenatal Steroids NOT RECEIVED 61 RECEIVED 4 Note: Table made from pie chart. Figure 3. PROM Versus Aetiology of Respiratory Distress HMD 6 MAS 6 PNEUMONIA 4 TTNB 1 BIRTH ASPHYXIA 1 Note: Table made from pie chart.
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|Title Annotation:||Original Research Article|
|Author:||Reshmi; Manjunatha; Bharamakkanavar, Sagar|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Mar 25, 2019|
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