Respiratory Distress in Full Term Neonates in the First Week of Life in Basrah Maternity and Children Hospital

Objectives: a descriptive study was carried out on term neonates with respiratory distress in the early neonatal period who was admitted to the neonatal care units in Basrah Maternity and Children Hospital to assess the causes, outcome, and neonatal, maternal, labor, and delivery characteristics. Patients and Methods: a total of (167) full term neonates, (103) males and (64) females, their ages range from less than one hour to 7 days who were admitted for respiratory distress (from the first of March to the end of August 2010) were recruited in the study from a total of (2858) cases admitted to the 1st and 2nd neonatal care units during the study period, (1348) of them had respiratory distress. Detailed maternal, perinatal, labor and delivery histories were taken and full clinical examination was performed. Results: the most common presenting signs were chest retractions and tachypnea. Eighty four (50.3%) of cases were delivered by caesarean section. It was found that (78.4%) of cases had a gestational age less than 39 weeks and (80%.8) were less than 24 hours of age. Both are statistically significant with p value <0.00l. One hundred forty six) (87.4%) had a normal body weight (2500 to 4000 gm). Ninety one (54.5%( of cases need hospitalization for 3 days or more. It was found that 39(23.4%) of the mothers were risky regarding their ages (<18 years and >35 years) and (27.5%) of the cases had no antenatal care, 95% of mothers were not employed and had less than 10 years of schooling. It was found that 75 (44.9%) cases were due to Transient tachypnea of the newborn and 50.7% of them were delivered by elective caesarean section followed by birth asphyxia in 22(13.2%) cases; (16) (72.75%) of them were delivered vaginally. Meconium Aspiration syndrome was found in (9.6%) of cases, early sepsis in (8.4%), and pneumonia in (7.8%). Congenital heart diseases was responsible for (7.8%) of cases, while anemia was found in (4.2%) of total cases, pneumothorax in (3%) and Respiratory Distress Syndrome in only (1.2%). The deaths were 15(9%) from 167 cases, the commonest causes were found to be due to birth asphyxia and early sepsis, 13 deaths (12.6%) occurred among males and more deaths among those who were less than 39 weeks gestation (9.16%). The total deaths due to Respiratory Distress in the study period were (35) from a total (174) and (150) from a total of (680) deaths in the 1st and 2nd neonatal care units respectively which constitute one fifth of the total deaths. Conclusions: A wise and correct decision of timing of caesarean section is needed with prevention and management of asphyxia and sepsis in addition to adequate measures and facilities of treatment for hospitalized neonates. (MJBU,


INTRODUCTION
ild to moderate respiratory distress (RD) in fullterm neonate is a frequent condition resulting from defect in birth related changes with variable clinical course and complex etiology, and affect neonates after birth. [1] The incidence of respiratory dysfunction is inversely related to gestational age being more in 37-38 than, 39-42 weeks. [2] Acute respiratory disease is, beside prematurity, the leading cause for hospitalization in neonatal intensive care units. [3] Neonatal respiratory distress is a common problem confronting family physicians. It is the most common reason that sick neonates require transfer to a referral center; about 79% of all transports involved a baby with respiratory distress. Although respiratory distress may represent a benign, self limited process, it may also be the first sign of sepsis or serious cardiopulmonary disease. [4] The overall incidence of respiratory distress in term babies is (4.2%). [5] The clinical presentation of respiratory distress in the newborn includes: apnea, cyanosis, grunting, inspiratory stridor, nasal flaring, poor feeding, tachypnea (more than 60 breaths per minute), retractions in the intercostal, subcostal, or supracostal spaces. [6] The causes of respiratory distress can be divided into: upper airway abnormalities which include: choanal atresia, macroglossia, Pierre-Robin syndrome, lymphangioma, teratoma or other mediastinal masses, cysts, subglotic stenosis and laryngotracheomalacia, [7] lower airway abnormalities which include: Transient tachypnea of the newborn, Respiratory distress syndrome (hyaline membrane disease RDS), meconium aspiration syndrome, infection (e.g. pneumonia, sepsis). [8] Non-pulmonary causes include birth asphyxia, anemia, congenital heart diseases, congenital malformation, medications, neurologic or metabolic abnormalities, polycythemia, and pneumothorax. [9,10] Respiratory morbidity is an important complication of elective cesarean section (ECS) in term infants. The incidence of respiratory distress was reported in 6% of newborns delivered by ECS versus 1% in infants born vaginally. [11] Deliveries by cesarean section continue to increase in both developed and developing countries, rates as high as 50% have been reported in some regions. [12] One third of RDS cases are potentially avoidable. [13] Infants born at 37-38 wk by elective delivery are 120 times more likely to receive ventilatory support for surfactant deficiency than those born at 39-41wk. [14] A significant reduction in neonatal RDS would be obtained if ECS was performed after 39 gestational weeks of pregnancy. [15] Some studies had shown that delaying non-urgent elective caesarean section until 39 weeks is much more effective in avoiding neonatal admission than giving antenatal steroids. [16] Neonates with respiratory distress are 2-4 times more likely to die than those without respiratory distress so its prevention and adequate management will decrease mortality. [17] This descriptive study was carried out to evaluate the cases of respiratory distress in early neonatal period in relation to causes, outcome, neonatal, maternal, labor and delivery characteristics in full term neonates.

PATIENTS AND METHODS Patients
A descriptive study had been carried out on 167 full term neonates (gestational age 37 weeks and more) who were admitted to Basrah Maternity and Children Hospital with signs of respiratory distress in both neonatal care units, the first neonatal unit (inborn cases) and the second neonatal care unit (outborn) for 6 months period from the first of March till the end of August 2010. The total admission during same period was 2858, 1348 of them were fullterm with Respiratory distress, 167 cases of them were studied. Their ages range from one hour to7 M days, (103) of them were males and (64) were females.

Data Collection
A special questionnaire was designed for the purpose of the study. The following information were taken: name, age at admission, sex, and residence of the family, date of admission and date of discharge or death. Neonatal data included: body weight, gestational age according to the date of last menstrual period of the mother, singleton or multiple births, Apgar score if available, need for resuscitation after birth, days of hospitalization. Factors related to labor and delivery were assessed including: type of delivery (vaginal or cesarean section= elective or emergency), place of delivery (home or hospital), complications (prolonged rupture of membranes >18 hr, prolonged labor, meconium staining of liquor, antepartum hemorrhage and others). Maternal information were recorded including: age (high risk group <18 yr or >35 yr and low risk group 18-35 yr, [18] parity (which is divided into risk group=P0 or ˃ P4 and normal group = P1-4), any medical disease, antenatal care attendance (if present or not), history of any sign of infection before labor, maternal education and work also were inquired. Full examination was done for all patients concentrating on assessment of gestational age (depending on Ballard Scoring System) [18] and only fullterm were included in the study with signs of respiratory distress (grunting, cyanosis, retractions, tachypnea or apnea), all were weighed and classified to risky weight ﴾small for gestational age (SGA) ≤ 2.5 kg and large gestational age (LGA) ≥ 4 kg﴿ and normal weight group(2.5-4 kg). Chest x-ray was sent for all patients and classified into normal and abnormal findings (depending on opinion of the physician and radiologist). Then they were followed in the ward for duration of hospitalization and outcome) The frequency of RD and deaths were calculated from total admission and total deaths. Neontal, maternal, labour characteristics were studied with causes of RD and deaths. An informed consent was obtained from the family for recruitment in the study.

Statistical analysis
Statistical analysis was done using SPSS program (version15), data were expressed and comparisons of proportions was performed using the chi square, P-value of < 0.05 was considered as statistically significant. Descriptive summarization of the data consisted of frequency counts and percentages. Fisher , s Exact Test was used whenever applicable.

RESULTS
Nearly 50% of admission was due to RD and 20% of deaths were due to RD, (Table-1).

*NCU= neonatal care unit
The majority of patients (78.4%) were between (37-38) weeks of gestation, males were 103(61.7%) and were less than 24 hours of age in 135(80.8%) of cases. There are statistically significant differences regarding sex distribution, gestational age and postnatal age, (

DISCUSSION
Respiratory distress is one of the most common reasons for admission to the neonatal care unit. Some causes are relatively innocent, but others are potentially life threatening. [4] During the study period, about half of the total admissions to the 1 st and 2 nd neonatal care units were due to respiratory problems in fullterm neonates and their death was nearly 20% of the total deaths. Regarding the number of cases, the result was similar to another study in Switzerland which found that respiratory distress was diagnosed in (52.8%) of all admitted neonates to the neonatal care units and the mortality was about (3.5%). [19] This indicates that the admission rate because of respiratory distress in fullterm neonates is high due to the presence of multiple causes, [19] while the mortality is low in such a developed country due to availability of resuscitation facilities like ventilators and surfactant therapy. Most fullterm neonates who were admitted to the neonatal care unit for respiratory distress were found to be less than 39 weeks of gestation. This result is similar to that reported by Stutchfield [16] and Madar et al, [14] who demonstrated an increased incidence of respiratory distress with decreasing gestational age from 41 to 37 weeks. Donaldsson, et al [2] reported that the incidence of respiratory dysfunction was inversely related to the gestational age even in the term infants. Wax et al [13] showed that infants born at 37-38 weeks were at significantly increased risk for severe respiratory distress syndrome (RDS), and deaths. The explanation for this is that with increasing gestational age the lungs become sufficiently mature to support respiration and the incidence of hyaline membrane disease decreases rapidly. [20] This study demonstrated that males were more frequently affected than females and the death was more among them. This is the same as Stutchfield [16] and Roth-Kleinberg et al, [3] who stated that male sex is a risk factor for respiratory distress. The cause for that is unexplained. [19] This study showed that about (24.6%) of those neonates required resuscitation after birth and majority were less than 24 hour of age or at immediate period after birth at time of admission this might increase the concern about the importance of perinatal factors as a cause for hypoxia which may lead to respiratory distress. Regarding maternal characteristics, majority of mothers are not employed, and of low education. The same finding was reported by Hansen et al [12] who had shown that the risk of respiratory morbidity in term infants was more if the mother had less than 10 years of schooling . Educated mothers know how to deal with their babies and know when to seek advice also low education is one of the factors that contribute to high risk pregnancy. [9] The deaths were more among infants of low educated mothers. Regarding delivery, this study demonstrated that large number of cases were delivered by caesarean section, this might be associated with increased number of iatrogenic caesarean section for many causes like wrong calculation of gestational age, repeated caesarean section or for tubal ligation and many studies demonstrated an increase in the incidence of respiratory distress due to iatrogenic caesarean section. [20] In the present study, the commonest clinical diagnosis was transient tachypnea of the newborn (TTN), half of them were delivered by elective caesarean section, Hales et al, [20] found that TTN was more frequent in infants born by cesarean section in the absence of labor, this finding can be explained by the possibility that labor and delivery enhance neonatal lung adaptation by inducing a surge of catecholamines in the fetus which stimulate the absorption of fetal lung fluid, inhibit secretion of fetal lung fluid and increase the release of surfactant. [12] This is similar to a study by Zanardo, et al [15] and Dehdashtian et al in Iran. [11] Derbent, et al [21] observed that vaginal delivery had a protective effect compared with elective caesarean section delivery for all gestational age groups. The potential beneficial effect of compression in the birth canal remains a plausible explanation. [22] Birth asphyxia was found to be 2 nd cause of RD. [1] Asphyxia was also found to be important an cause of RD in other study by Majeed et al [10] who showed that (46%) of neonates with birth asphyxia presented with respiratory distress and pulmonary dysfunction may be caused by meconium aspiration syndrome or persistent pulmonary hypertension, it also results in brain stem malfunction with the impairment of respiratory derive. [9] The present study demonstrated that most cases of early sepsis were delivered by vaginal route, this is the same as Jain et al [23] in Nepal, who showed that more than half of the cases with suspected sepsis were delivered vaginally. Regarding deaths, it was found that (9%) of cases died, mostly due to birth asphyxia, and early sepsis. A study in India done by Bang et al [24] showed that sepsis was the primary cause of death in 52% of neonatal deaths, while Webber, et al in the United Kingdom [25] demonstrated that death due to pneumonia in neonates presented in the 1 st week of life was 14%. Mathur et al, [17] showed that the fatality in neonates with meconium aspiration was 50% and due to pneumonia was 25.8% but no death was reported in neonates with TTN. Early term neonates (37-38) weeks of gestation and were found to have more deaths, that is because the incidence of respiratory dysfunction is inversely related to the gestational age even in the term infants and they are at significantly increased risk for severe RDS. [2,12] Thus delaying non-urgent elective caesarean section until 39 weeks gestation, wise indication of caesarean section to decrease iatrogenic respiratory distress, management of asphyxia and sick infants are recommended to decrease RDS among full term early neonates