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Significance of Nucleated RBC Count in Term Neonates with Asphyxia Neonatorum

*l Post Graduate, Department of Paediatrics, RMMCH, Chidambaram-608002,Tamilnadu, India 2 Associate Professor, Department of Paediatrics, RMMCH, Chidambaram-608002,Tamilnadu, India 3 Professor, Department of Paediatrics, RMMCH, Chidambaram-608002,Tamilnadu, India ABSTRACT Objective: To study the correlation of nucleated red blood cell (NRBC)/100 white blood cell (WBC) count with perinatal asphyxia in terms of severity and short term outcome. Material and Methods: A prospective, comparative case-control study was undertaken at RMMCH Chidambaram from January 2015 to July 2016, which included a total of 100 neonates with 50 asphyxiated babies (case group) and 50 normal babies (control group). The venous blood was collected immediately after delivery for measurement of NRBC/100 WBC. Early neonatal outcome of both groups was also evaluated in relation to the NRBC/100 WBC count. Statistical analysis was performed. Results: The mean NRBC/100 WBC count was 16.76±11.46 in case group and in control group 3.78±2.79. Also a statistically significant correlation existed between severity of asphyxia (stage of hypoxic-ischemic encephalopathy [HIE]), poor outcome and higher number of NRBC/100 WBC count. Conclusion: It is an inexpensive and easily available procedure to evaluate perinatal asphyxia, especially in a resource poor country, where blood gas analysis facilities are not available in majority of places. Also, it is a good predictor of short-term outcome of asphyxiated babies.


Introduction
Aphyxia neonatorum, also called birth or newborn asphyxia, is defined as failure to start regular respiration within a minute of birth. Asphyxia neonatorum is a neonatal emergency as it may lead to hypoxia (lowering of oxygen supply to the brain and tissues) and possible brain damage or death if not correctly managed. Newborn infants normally start to breathe without assistance and usually cry after delivery. By one minute after birth most infants breathe well. If an infant fails to establish sustained respiration after birth, the infant is diagnosed with asphyxia neonatorum.
Perinatal asphyxia is a major cause of acute mortality and chronic neurologic disability amongst survivors, and is a complication that occurs between 2-10% of deliveries. 1   Profound metabolic or mixed acidemia (pH <7) in an umbilical blood sample and persistence of an Apgar score of 0-3 for longer than 5 minutes.  Neonatal neurologic sequelae (e.g-seizure, coma, hypotonia)  Multiple organ involvement (e.g-kidney, lungs, liver, heart and intestines). But, as per Cloherty et a1 3 perinatal asphyxia is defined as a condition of fetal hypoxia and hypercarbia, identified by fetal acidosis as umbilical artery pH <7. The condition can be diagnosed by fetal distress, meconium aspiration, low Apgar score <6 by 5 minutes, umbilical cord blood pH <7. Recent studies on hematological variations in asphyxiated neonates as a predictor of neonatal asphyxia have suggested that number of nucleated red blood cells (NRBCs) in cord blood of asphyxiated neonates help in identifying birth asphyxia. The number of NRBC/100 white blood cells (WBC) is quite variable but is rarely >10. [4][5][6][7] The instances, where number of NRBCs exceed 10/100 WBC are asphyxia, prematurity, Rh-sensitization, maternal diabetes mellitus and intrauterine growth retardation. Considering the hematopoietic response to hypoxia in utero the elevated NRBC/100 WBC count is being hailed as the marker for not only perinatal asphyxia but also the chances of the neonates to develop neurological sequelae. 4,7-10

Materials and Methods
A prospective case control study was conducted in NICU, RMMCH. A total of 100 newborns were enrolled after consent from parents, 50 were cases with birth asphyxia who met the inclusion criteria of Apgar score <3/10 at 1 minute and controls were with Apgar score >7/10 at 1 minute. Preterm babies, babies with downs syndrome, TORCH, sepsis & Rh incompatibility with hemolysis were excluded. 2m1 of venous blood collected within 6 hours of birth and used for making peripheral smears with Leishman stain and complete blood counts. Number of NRBC were counted per 100 WBC in peripheral smear and were reported.

Results
There is no statistical significant difference in the age, parity status, gestational age of mother, birth weight and mode of delivery between cases and control newborns. The Apgar score at different intervals are comparatively less in cases than in controls. The monocytes and NRBC count are significantly higher in cases than in controls. The majority of cases have NRBC count between 10-19 per 100 WBC whereas 98% of controls have NRBC count of 0-9 per 100 WBC. There is negative correlation between Apgar score and NRBC values. There is statistically significant positive correlation is observed between HIE stage and NRBC values. That is, when HIE stage is higher, NRBC values is also higher and vice versa. There is statistically positive con-elation between NRBC with time of onset of direct breastfeeds, NICU stay, reflex recovery, cry/sucking/activity and hospital stay. All the parameters are delayed if NRBC count is more as shown in the above Table. The delay is maximum for cases with ≥ 20 NRBC count.

Discussion
In the present study, attempt has been made to evaluate the relation of venous blood NRBC/100WBC in predicting perinatal asphyxia and its immediate outcome.  9 Sikarwar and Gupta; 11 Phelan et al; 5 Philip and Tito, 6 who found that NRBC increases with increase in stages of HIE. Our study also revealed increased NRBC/ 100WBC count with low Apgar scores many authors like Hanlon-Lundberg and Kirby, 12 Boskabadi et al, 13 Saracoglu et al, 10 had reported similar findings in their studies.

Conclusion
Thus in this study venous blood NRBC count has shown to be a good predictor of perinatal asphyxia. It is cost-effective and does not require any special expertise or any high-tech facilities, it may be a useful, reliable, inexpensive and easily available marker to evaluate perinatal asphyxia, specially in a resource poor country, where blood analysis facilities are not available in majority of place.