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CLINICOETIOLOGICAL PROFILE OF RESPIRATORY DISTRESS IN NEONATES.

BACKGROUND

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. [1]

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. [2]

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.

Sampling Technique

Convenient sampling.

Study Design

Cross sectional descriptive study.

Inclusion Criteria

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 [3]

Exclusion Criteria

* Neonates with respiratory distress who were born outside our hospital and was referred to us for management of respiratory distress. [4]

* Babies born in our hospital but developing respiratory distress after 28 days of Life. [5]

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).

RESULTS

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).

DISCUSSION

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, [6] the majority of cases were hyaline membrane disease followed by meconium aspiration syndrome. Dutta et al [7] and Kumar et al [8] in their study had a highest incidence of transient tachypnoea of newborn. Mathur et al [9] 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. [10]

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 [11] 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 [7] 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 [12] 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. [13] 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 [14] and Liu et al. [15]

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.

CONCLUSION

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%.

REFERENCES

[1] Hermansen CL, Lorah KN. Respiratory Distress in the Newborn. Am Fam Physician 2007;76(7):987-94.

[2] Ersch J, Roth-Kleiner M, Baeckert P, et al. Increasing incidence of respiratory distress in neonates. Acta Paediatrica 2007;96(11):1577-81.

[3] Report of the National Neonatal Perinatal Database (National Neonatology Forum) 2002-03.

[4] Abdelrahman SMK, Hamed SM, Nasr A. Neonatal respiratory distress in Omdurman Maternity Hospital, Sudan. Sudan J Paediatr 2014;14(1):65-70.

[5] Santosh S, Kumar KK, Adarsha E. Clinical study of respiratory distress in newborn and its outcome. Indian Journal of Neonatal Medicine and Research 2013;1(1):2-4.

[6] Clark RH. The epidemiology of respiratory failure in neonates born at an estimated gestational age of 34 weeks or more. Journal of Perinatology 2005;25(4):251-7.

[7] Dutta A, Sinhamahapatra TK, Gayen S, et al. Spectrum of respiratory distress in newborn: a study from a tertiary care hospital in Kolkata. The Child and Newborn 2011;15(2):45-8.

[8] Kumar A, Bhat BV. Epidemiology of respiratory distress of newborns. Indian J Pediatr 1996;63(1):93-8.

[9] Mathur NB, Garg K, Kumar S. Respiratory distress in neonates with special reference to pneumonia. Indian Pediatrics 2002;39(6):529-37.

[10] Rubaltelli FF, Bonafe L, Tangucci M, et al. Epidemiology of neonatal acute respiratory disorders. A multicenter study on incidence and fatality rates of neonatal acute respiratory disorders according to gestational age, maternal age, pregnancy complications and type of delivery. Italian Group of Neonatal Pneumology. Biol Neonate 1998;74(1):7-15.

[11] Li-Ling Q, Cui-Qing L, Yun-Xia G, et al. Current status of neonatal acute respiratory disorders. Chin Med J 2010;123(20):2769-75.

[12] Dani C, Reali MF, Bertini G, et al. Risk factors for the development of respiratory distress syndrome and transient tachypnoea in newborn infants. Italian Group of Neonatal Pneumology. Eur Respir J 1999;14(1):155-9.

[13] Ashtekar SD, Ashtekar RS, Kumbhar SK, et al. Clinical study of meconium aspiration syndrome in relation to birth weight and gestational maturity at general hospital Sangli. Med Pulse--International Medical Journal 2014;1(5):189-92.

[14] Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97(3):439-42.

[15] Liu J, Yang N, Liu Y. High-risk factors of respiratory distress syndrome in term neonates: a retrospective case-control study. Balkan Med J 2014;31(1):64-8.

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.

E-mail: manjunatha0505@gmail.com

DOI: 10.14260/jemds/2019/198
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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Article Details
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Title Annotation:Original Research Article
Author:Reshmi; Manjunatha; Bharamakkanavar, Sagar
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:Mar 25, 2019
Words:2081
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