Thesis (M.D.)--University of Pennsylvania, 1802. / Microform version available in the Readex Early American Imprints series.

Thesis (M.Sc.(Med.))--University of the Witwatersrand, Faculty of Health, 2013.

xi, 283 leaves : / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (M.D. 1972) from the Dept. of Obstetrics and Gynaecology, University of Adelaide

Thesis (M.D. 1972) from the Dept. of Obstetrics and Gynaecology, University of Adelaide.

A Research Report submitted to the Faculty of Science, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Master of Medicine in Paediatrics. 8 May 2014 / Background: Perinatal asphyxia is a significant cause of death and disability. Aim: To determine the outcomes (survival to discharge and morbidity post discharge) of neonates with perinatal asphyxia at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Methods: This was a descriptive retrospective study. Patient information was obtained from the computerised neonatal database of neonates admitted to CMJAH within 24 hours of birth between 1 January 2006 and 31 December 2011 with a birth weight of >1800 grams and a 5 minute Apgar score <6. Results: 450 babies were included in the study; 185 females (41.1%). Mean birth weight was 3034.80 grams (SD 484.936) and mean gestational age was 39.11 weeks (SD 2.2). Most babies were inborn 391/450 (86.9%) and most were delivered by normal vaginal delivery 270/450 (60%). The overall survival was 390/450 (86.6%). There were 42 babies admitted to ICU. The ICU survival was 37/42 (88.1%). Significant predictors of survival were place of birth (p value 0.006), mode of delivery (p value 0.007) and bag mask ventilation at birth (p value 0.040). The duration of stay (p value 0.000) was significantly longer in survivors (6.49 days SD 6.6). The remaining factors were not significantly different between the two groups. The rate of perinatal asphyxia (Apgar score <6) was 4.68 per 1000 live births; while 3.61 per 1000 live births had evidence of hypoxic ischaemic encephalopathy (HIE). Of the 390 babies discharged from CMJAH, 113 had follow up records (28.97%) to a mean corrected age of 5.88 months (SD 5.03). The majority (90/113 – 79.64%) had normal development. Conclusion: i) The high overall survival and survival after ICU admission provides a benchmark for further care. ii) Obtaining adequate data for long term follow up was not possible with the existing resources and surrogate early markers of outcome and / or more resources to ensure accurate follow-up are needed and iii) the high incidence of HIE suggest that a therapeutic hypothermia service including long-term follow-up component would be beneficial.

This study addresses the problem of asphyxia neonatorum in a developing African community in the Mdantsane region of Ciskei. It also documents asphyxia as a prominent cause of childhood handicap, examines aspects of its epidemiology and evaluates the effectiveness of a regimen of phenobarbitone and dexamethasone in limiting subsequent neurological deficit in asphyxiated neonates. Analysis of neonatal deaths at Cecilia Makiwane Hospital over an 18-month period showed that asphyxia accounted for one third of all neonatal deaths. In particular, asphyxia caused two thirds of deaths in infants over 2 Kg birth weight. From a hospital register of handicapped children, 211 had cerebral palsy. Asphyxia was the cause of cerebral palsy in 33% of these children. Spastic quadriplegia, the type of cerebral palsy most often resulting from the cerebral damage associated with asphyxial hypoxic-ischaemic insults, was by far the largest diagnostic category (57%). Asphyxia therefore appears to be the single largest cause of significant handicap in Ciskei. In view of the underdeveloped support services to parents in most developing areas, the problem of asphyxia is of considerable importance. In the study of the epidemiology of asphyxia, details of pregnancy and labour were obtained for 163 asphyxiated term infants and 2758 non- asphyxiated term infants whose mothers had delivered in the hospital. The factors positively associated with asphyxia were: low gravidity and parity, failure to book for antenatal care, the occurrence of antenatal disorders, the occurrence of fetal distress, a prolonged first stage of labour and delivery by caesarean section or vacuum extraction. Maternal age and the actual number of antenatal visits were not associated with asphyxia. The causes of asphyxia assigned by the specialist obstetrician in charge were cephalopelvic disproportion (CPD) (39%), utero-placental pathologies (22%), other (8%), and "unknown" where he could find no abnormality in pregnancy and labour (27%). From these findings it appears that the steps that need to be taken for prevention include: active recruitment of patients to book for antenatal care, more active detection and management of cephalopelvic disproportion and basic research to elucidate the causes of the "unknown" group whom it is speculated have undetected utero-placental pathology.

The brain requires a continuous supply of oxygen and nutrients, and even a short period of reduced oxygen supply can cause severe and lifelong consequences for the affected individual. The unborn baby is fairly robust, but there are of course limits also for these individuals. The mostsensitive and most important organ is the brain. When the brain is deprivedof oxygen, a process can start that ultimately may lead to the death of braincells and irreparable brain damage. This process has two phases; one more orless immediate and one delayed. There is a window of time of up to 24 hourswhere action can be taken to prevent the delayed secondary damage. One recently clinically available technique is to reduce the metabolism and thereby stop the secondary damage in the brain by cooling the baby.It is important to be able to quickly diagnose hypoxic injuries and to followthe development of the processes in the brain. For this, the electroencephalogram (EEG) is an important tool. The EEG is a voltage signal that originates within the brain and that can be recorded easily andnon-invasively at bedside. The signals are, however, highly complex and require special competence to interpret, a competence that typically is not available at the intensive care unit, and particularly not continuously day and night. This thesis addresses the problem of automatic classification ofneonatal EEG and proposes methods that would be possible to use in bedside monitoring equipment for neonatal intensive care units.The thesis is a compilation of six papers. The first four deal with the segmentation of pathological signals (burst suppression) from post-asphyctic full term newborn babies. These studies investigate the use of various classification techniques, using both supervised and unsupervised learning.In paper V the scope is widened to include both classification of pathologicalactivity versus activity found in healthy babies as well as application of thesegmentation methods on the parts of the EEG signal that are found to be of the pathological type. The use of genetic algorithms for feature selection isalso investigated. In paper VI the segmentation methods are applied onsignals from pre-term babies to investigate the impact of a certain medication on the brain.The results of this thesis demonstrate ways to improve the monitoring of the brain during intensive care of newborn babies. Hopefully it will someday be implemented in monitoring equipment and help to prevent permanent brain damage in post asphyctic babies.

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