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Fetal Asphyxia: Pathogenic Mechanisms and Consequences 57 CHAPTER © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORFetal SALE OR Asphyxia: DISTRIBUTION PathogenicNOT FOR SALE OR DISTRIBUTION Mechanisms and Consequences © Jones & Bartlett Learning, LLC © Jones5 & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Hypoxia is defined as a reduced or insufficient level of oxygen in the body’s tissues. In clinical and physiologic usage, the term is generally reserved for more substantial degrees of reduced O2 avail- ability, such as occurs at moderately high altitude when a person notices the O2 limitation. When one © Jonestravels &from Bartlett sea level Learning, up to 10,000 feet,LLC mild forms of discomfort© may Jones be noted & suchBartlett as tachypnea, Learning, LLC NOTtachycardia, FOR SALE exercise OR intolerance, DISTRIBUTION and headache, and in general, theNOT higher FOR the altitude,SALE ORthe greater DISTRIBUTION the discomfort. Hypoxia in both adults and fetuses is thus a continuum from normoxia, to easily tolerated reduced O2, to a reduction requiring physiologic adaptation such as tachypnea, to reduced function, to tissue damage, and finally to death. These and other terms are defined in Table 5-1. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Table 5-1 Definition of Terms Related to Hypoxia Acidemia Increased concentration of hydrogen ions in the blood Acidosis Increased concentration of hydrogen ions in the tissues of the body Aerobic metabolism© Jones Metabolism& Bartlett of glucose Learning, using oxygen; LLC aerobic metabolism generates© 38 Jonesmolecules & of Bartlett Learning, LLC NOT FORadenosine SALE triphosphate OR DISTRIBUTION (ATP) per each glucose molecule for energyNOT use FOR SALE OR DISTRIBUTION Anaerobic metabolism Metabolism of glucose without the use of oxygen; anerobic metabolism generates 2 molecules of ATP per each glucose molecule for energy use Asphyxia Comes from the Greek word for “pulseless”; a decrease in O2 and increase in CO2 due to an interference with gas exchange; asphyxia is a continuum described by degrees of © Jones & Bartlett Learning,acidosis LLC © Jones & Bartlett Learning, LLC NOT BaseFOR SALE OR DISTRIBUTIONA substance that is capable of accepting hydrogenNOT ions FORand thereby SALE decreasing OR DISTRIBUTIONacidity 2 Base excess (BE) The amount of base or HCO 3 that is available for buffering; as metabolic acidosis increases, the base excess decreases 2 2 Bicarbonate (HCO 3 ) HCO 3 (often referred to as bicarb) is the base or hydrogen acceptor that is part of the © Jones & Bartlett Learning, LLC primary buffering system ©within Jones the blood & Bartlett Learning, LLC NOT FOR SALE ORBuffer DISTRIBUTIONA buffer is a chemical substanceNOT that FOR is both SALE a weak ORacid andDISTRIBUTION salt, and can absorb or give up hydrogen ions, thereby maintaining a constant pH value; the primary buffer 2 involved in fetal oxygenation is HCO 3 Hypercarbia Excessive carbon dioxide in blood; sometimes referred to as hypercapnia Hypoxia © Jones Decreased& Bartlett oxygen Learning, in tissue LLC © Jones & Bartlett Learning, LLC Hypoxemia NOT FORDecreased SALE oxygen OR DISTRIBUTIONcontent in blood NOT FOR SALE OR DISTRIBUTION Hypoxemia–ischemia Reduced amount of oxygen and inadequate volume of blood delivered to tissues; can cause brain injury if delivery of oxygen and glucose falls below critical levels Metabolic acidemia Low bicarbonate (negative base excess) Mixed acidosis Low pH that reflects both increased carbon dioxide and decreased base excess © Jones & Bartlett Learning,(i.e., increased LLC lactic acid) © Jones & Bartlett Learning, LLC NOT FORpH SALE OR DISTRIBUTIONpH refers to the concentration of hydrogen ionsNOT in blood FOR and refersSALE to “puissance OR DISTRIBUTION hydrogen,” which is French for strength (or power) of hydrogen; a pH of 7.0 = 0.0000001 (which is 1027) moles per liter of hydrogen ions Respiratory acidemia High PCO2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The authors would like to acknowledge Dr. Austin Ugwumadu for his contributions to this chapter. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 9781284090338_CH05.indd 55 17/03/17 2:08 PM 56 PART II Physiology © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORIn DISTRIBUTION the fetus, the continuum of hypoxia is mostlyNOT caused FOR by SALE a reduction OR DISTRIBUTIONof either maternal pla- cental (i.e., intervillous) blood flow, or reduced umbilical blood flow. Both of these factors result in reduced exchange of the respiratory gases, so in addition to hypoxia there is also a buildup of carbon dioxide, resulting in what is called a respiratory acidosis. At more severe degrees of reduc- tion of these© two Jones blood &flows, Bartlett and therefore Learning, more severeLLC hypoxia, the cells of the© body Jones will convert& Bartlett Learning, LLC from aerobicNOT to anaerobic FOR SALE metabolism OR DISTRIBUTIONfor energy production, of which the end productNOT FOR is lactic SALE OR DISTRIBUTION acid. This results in reduction of bicarbonate, and therefore a metabolic acidosis (Figure 5-1). Hypoxemia is used to describe a reduced level or concentration of O2 in the blood. The direct measurement of hypoxia in tissues is rarely possible, so measurements of oxygen in the blood are © Jonesused as & surrogates. Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORHypoxia–ischemia SALE OR describesDISTRIBUTION reduced amount of oxygen and inadequateNOT FOR blood SALE flow OR in tissue. DISTRIBUTION The combination of hypoxia and ischemia can cause brain damage when oxygen and glucose delivery fall below critical levels. Asphyxia has the pathologic meaning of insufficiency or absence of exchange of the respiratory © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC gases, though etymologically it comes from the Greek word meaning pulseless. Although the word NOT FOR SALE ORasphyxia DISTRIBUTION strictly could be applied to any changeNOT in respiratory FOR SALE gas levels OR from DISTRIBUTION normal, by common usage it is generally reserved for the more severe degrees, where compensatory mechanisms are required for tolerance, or tissue damage or death occurs. The severity© Jones of hypoxia & Bartlettor asphyxia Learning, is described LLCin terms of acidemia, hypercarbia,© Jones hypoxemia, & Bartlett Learning, LLC and base excess.NOT In FOR this text, SALE we use OR the DISTRIBUTION terms hypoxia and asphyxia to denote theNOT moderate FOR or SALE OR DISTRIBUTION more severe degrees when the fetus uses physiologic alterations to tolerate the condition. There are basically three common means by which the human fetus can become hypoxic or asphyxiated: (1) insufficiency of uterine blood flow1; (2) insufficiency of umbilical blood flow2; or 3 © Jones(3) a decrease & Bartlett in maternal Learning, arterial LLC oxygen content. Each of these© mechanismsJones & Bartlett converges Learning,into a LLC NOTcommon FOR SALE pathway OR that DISTRIBUTION involves the fetal response to reduction ofNOT available FOR oxygen. SALE In ORaddition, DISTRIBUTION the Insufficient oxygen delivered to fetus Elevated carbon dioxide © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONAnaerobic metabolism used to NOT FOR SALE OR DISTRIBUTION generate ATP Increased H2CO3 Lactic acid, an end product of © anaerobicJones metabolism,& Bartlett accumulates Learning, LLC © Jones & Bartlett Learning, LLC NOT FORin the fe SALEtal compartment OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Metabolic acidosis Respiratory acidosis © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC Reduced© Jones pH & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Figure 5-1 Consequences of insufficiency of exchange of respiratory gases. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 9781284090338_CH05.indd 56 17/03/17 2:08 PM Chapter 5 Fetal Asphyxia: Pathogenic Mechanisms and Consequences 57 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORfetus DISTRIBUTION has higher oxygen needs during pyrexia, NOTwhich FORmay play SALE a role OR in the DISTRIBUTION known increased risk for newborn neurologic damage following chorioamnionitis.4,5 Other mechanisms, such as fetal anemia, are relatively rare in clinical practice. The two organ systems that have the most critical roles in the fetal response to hypoxia are the cardiorespiratory© Jones and central & Bartlett nervous Learning, systems. In both, LLC the initial response involves© Jones a series of& Bartlett Learning, LLC physiologic NOTchanges FOR that devolveSALE toOR pathologic DISTRIBUTION responses when asphyxia persists.NOT Similarly, FOR in SALEboth OR DISTRIBUTION systems the response to acute hypoxial stress is different than the response to chronic hypoxia. The sections that follow address physiologic and pathologic responses to acute hypoxia first followed by the effects of chronic hypoxia. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTI. FOR FET SALEAL OR C ADISTRIBUTIONRDIORESPIRATORYNOT RES FORPONSES SALE OR DISTRIBUTION TO HYPOXIA In the previously normoxic fetus, a number of compensatory mechanisms occur during acute hy- © Jones & Bartlettpoxia
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