11. diseases of the newborn. Clinical and morphological assessment of the newborn. Flashcards
what are the main diseases of new borns ?
asphyxia
hypoglycaemia
hyperbilirubinemia
CNS
seizures
malformation : choanal atresia herniation of diaphragm oesophageal atresia omphalocele gastrochisis heart anomalies
there are three types of asphyxias what are they ?
prepartum -
intrauterine
during labour
postnatally
what causes prepartum intrauterine asphyxia ?
placental abnormalities placental abruption
maternal diseases like diabetes
drop in blood pressure
anemia ,
foetus has the umbilical cord wrapped around the neck
knotting of umbilical cord
what causes asphyxia during labour ?
due to umbilical cord compression
umbilical cord prolapse
what causes asphyxia postnatally
respiratory distress -
RDS / hyaline membrane disease
meconium aspiration
amniotic aspiration
===== this can cause respiratory distress: metabolic acidosis hypothermia hypoglycaemia
what is the most severe outcome of asphyxia
hypoxic -ischemic encephalopathy - leads to irreversible neurological damage
manifested as intellectual disability
developmental delay
spasticity
or multiple organ failure
how is intrauterine asphyxia diagnosed
done through blood being drawn from the umbilical cord and running blood gas analysis on it
Profound metabolic acidosis
fetal distress
Tachycardia : > 160 beats / min. due to sympathetic stimulation caused by mild
hypoxia.
ii) Bradycardia: < 100 beats / min due to vagal stimulation caused by moderate hypoxia.
iii) Cardiac arrhythmia (irregular FHR) : due to severe hypoxia. It is the most dangerous one.
iv) Late deceleration.
signs and symptoms for respiratory distress syndrome/
tachypnea > 60 breaths per min (30-60 is normal)
nasal flaring
expiratory grunting
Rib retraction
diagnosis of respiratory distress syndrome ?
low apgar score
in auscultation decreased breath sounds
blood gas analysis of fetes -
for respiratory distress syndrome - respiratory and metabolic acidosis
pco2 80 mmhg in severe cases
chest x ray - fine reticular granular lung opacities
what is the treatmnet for respiratory distress syndrome ?
CPAP with with Positive end expiratory pressure of 3-8cm h20
start intubation with mechanical ventiation if Respiratory acidosis with a PaCO2 > 50 mm Hg, a PaO2 < 50 mm Hg or O2 saturation <90% persists
Acidosis should be corrected by intravenous administration of sodium bicarbonate
endotracheal administration of exogenous surfactant within 2 hours postpartum
what is a big complication of respiratory distress syndrome ?
bronchopulmonary dysplasia chronic lung disease primarily found in premature infants exposed to prolonged mechanical ventilation and oxygen therapy for neonatal RDS
increased chance in neonates treated with more than 21% oxygen for at least 28 days
Diagnostics
Chest x-ray: diffuse, fine, granular densities,
areas of atelectasis interspersed with areas of hyperinflation
Therapy: controlled oxygenation, bronchodilators diuretics, possibly glucocorticoids
what are other complication of HMD?
infection and pneumothorax
to whom does meconium aspiration syndrome occur ?
term or post-term babies who are small for gestational age (IUGR)
diagnosis of meconium aspiration ?
Aspiration of meconium from the trachea at birth
or visualised in vocal cords
meconium in amniotic fluid
in auscultation - rales and rhonchi
Radiologically hyperinflated lung fields, flattened diaphragm with coarse and patchy infiltration
blood gas - hypoxemia and hypercapnia
management of meconium aspiration syndrome ?
Airway and oral suctioning may be needed
Liberal oxygen supply
Mechanical ventilation is required where PO2 is less than 50 mm Hg and PCO2 is above 50 mm of Hg.
Antibiotic coverage
there are 5 different types of post natal icterus what are they ?
icterus neonatal simplex icterus praecox icterus gravis kernicterus prolonged icterus
describe icterus neonatal simplex / physiological
starts at 2/3rd day of birth and not before - reaches peak at 5th day - vanishes in two weeks
physiological icterus from the not fully functioning liver
the levels of indirect bilirubin should not exceed 15mg/d
usually 12mg/dl in term
premature <15mg/dl
describe icterus praecox
mild jaundice presents first day of birth
it usually clears rapidly and spontaneously
what causes icterus praecox ?
due to RH ABO blood group incompatibility ( mother and fetus has different blood group and mother’s immune system may attack it causing hemolytic anemia
cephalohematoma (hemorrhage between skull and periosteum) or other traumas during birth
occasionally resulting in haemolytic disease but it quickly clears
intraventricular hemorrhage
neonatal - eccoli infection
USUALY NOT TREATMENT REQUIRED
what is icterus gravis
bilirubin is higher than 16mg/dl
DEVELOPS JAUNDICE WITHIN 24 HOURS
what causes icterus gravis ?
often the cause erythroblastosis fetalis - haemolytic anemia caused by transplacental transmission of maternal antibodies to red blood cells of fetus often due to the RhD antigens
defect in conjugation of bilirubin
Crigler-Najjar syndrome (autosomalrecessive), Gilbert syndrome(autosomaldominant),
Preterm babies with impaired liver function
describe kernicterus ?
higher than critical level of 20mg/dl where indirect bilirubin starts to deposit in the basal ganglia - leads to brain damage and retardation
CONJUGATED BILIRUBIN CANNOT CAUSE KERNICTERUS
what causes kernicterus ?
again due to haemolytic anemia - erythroblasts fetalis ,
liver enzymes present but not active
administration of aspirin - displaced bilirubin attached to albums
signs and symptoms of kernicterus ?
lethargy, hypotonia, poor feeding
severe illness is manifested by prostration, respiratory distress and finally opisthotonos, hyperpyrexia, convulsions, enlarged liver, spleen
quick diagnosis of kernicterus is ?
diagnosis is through - assymetrical moro reflex (spreading out arms , pulling arms in , crying)
asymmetrical moro reflex - (spreading out of arms , pulling arms in and crying -
rapidly lowering the infant while supported to a sudden stop and pinching the skin of the abdomen or head is tilted suddenly a few cm lower
every icterus except prolonged icterus can be treated with ?
treatments is introduced when bilirubin above 13mg/dl in term
11mg/dl in preterm
Adequate hydration
- put phototherapy (double from above and below )
using blue light rays convert the unconjugated bilirubin to conjugates
Phenobarbital therapy induces hepatic microsomal enzymes and increases bilirubin conjugation and excretion
Metalloporphyrins decreases bilirubin production by inhibiting heme oxygenase. Tin and zinc metalloporphyrins a
diagnosis of neonatal hyperbilirubinemia ?
clinical
dermal zone 1 - face and neck = 5mg/dl
dermal zone 2 - chest and back - 10mg/dl
dermal zone 3 - abdomen and below umbilicus to knees - 12mg/dl
dermal zone 4 - arms ad legs below knees- 15mg/dl
dermal zone 5 - feet and have - >15mg/dl
======
serum bilirubin level and total blood test
blood group status of mother and child
antibody screening of mother
direct coombs test for rh incompatibility
what is breast milk jaundice ?
The activity of the enzyme-glucuronyl transferase is inhibited by a specific steroids fatty acids of breast milk.
level rises from the 7th day after birth to max by 14th day. but less than 15mg/dl
rarely causes kernicterus.
no treatment.
If the bilirubin level is high temporary withdrawal of breastfeeding cures.
what causes CNS seizures ?
traumatic
hypoxic ischemicncephalopathy
neonatal asphyxia
intra cranial hemorrhage
metabolic
hypoglycemia
kernicterus
hypo/hypercalcemia
infective -high fever , cns strep b ore
coli
iatrogenic - narcotic withdrawl
premature and low birth weight
how do we treate sezuires in new borns ?
control convulsion :phenobarbitural
but be ready to intubate the newborn
what empirical treatment for neonatal sepsis
ampicillin and gentamicin
what are the causes for neonatal sepsis
Early-onset neonatal sepsis (within 1 week of birth) is typically caused by vertical or perinatal transmission to the fetus
most commonly caused by group b strep and ecoli
hsv
who are at high risk for neonatal sepsis ?
for preterm and low birth weight neonates ,
PROM
what are the symptoms for neonatal sepsis ?
symptoms -
fluctuations in temp
respiratory abnormalities
decreased milk drinking
diarrhea and decreased bowl movements
what is choanal atresia ?
back of nasal passage blocked usually by bony tissue or soft tissue due to failed recanalisation of the nasal fossa during fetal development
what are the signs and symptoms of choanal atresia
bilateral - cyanosis the baby through feeding
continuous stream of mucus draining from one or both noses
what is the treatment for choanal atresia ?
endotracheal tubing
extracorporeal membrane oxygenation
if bone obstruction then its drilled through drilled through and stent is placed
how is hernia of diaphragm diagnosed
routine ultrasound
Otherwise, it is diagnosed soon after birth when a baby shows signs of breathing difficulties
clinical management f herniation of diaphragm ?
nano gastric tube inserted - release any excess air in stomach and intestine which relives pressure on lungs
ventilator f respiration problems , extracorporeal membrane oxygenation if severe
then operation when everything is stable
what is omphalocele ?
abdominal wall defect in which intestines , lover and other abdominal organ may be outside in sac , failure of them going back into the abdominal cavity during 9th week of of gestation
what is the diagnosis of omphalocele ?
fetal ultrasond , elevated AFP
what is the treatment of omphalocele ?
Immediately after birth a nasogastric tube is required to decompress the intestines and an endotracheal intubation is needed to support respiration. The exomphalos sac is kept warm and covered with a moist saline gauze and plastic transparent bowel bag to prevent fluid loss.
surgery required
what is gastroschisis ?
baby’s intestines extend outside of the abdomen through a hole next to the belly button.
in gastroschisis the umbilical cord is not involved and the intestinal protrusion is usually to the right of the midline. Parts of organs may be free in the amniotic fluid and not enclosed in a membranous (peritoneal) sac
what is the diagnosis of gastroschisis ?
ultrasound and raised AFP
what is the clinical management of gastroschisis ?
same as omphalocele
heart defects which are cyanotic ?
tricuspid atresia
tetralogy of fallout - ventricular septal defect
pulmonary valve stenosis
right ventricular hypertrophy
overriding aota
transposition of great arteries
truncus arteriosus - the pulmonary arteries and aorta do not separate - one trunk arising from the heart with mixed blood supplied to coronary artery , lungs , and rest of body (perisirant - cyanotic)
what is a long term complication of hypoglycaemia ?
mental retardation
seizures
development delay
why is there physiological hypoglycaemia in new born ?
glucose is transferred from the mothers placenta but not insulin , the continuous glucose supply stops once after delivery
during last trimester glucose is stores in liver , heart and skeletal muscles
all new born experience glucose decline 2-3 hours after birth then maintained through regular feedings
how is hypoglycaemia defined ?
below 30mg/dl first 24 hours then glucose levels are below 45mg/dl
what are symptoms of hypoglycaemia ?
can show no symptoms hypothermia tremor hypotonia if severe seizures
what are the risk factors for hypoglycaemic baby ?
premature hypotrophic - not enough glycogen stores
hyperinuslinemic hypoglycaemia
gestational diabetes
type 1 diabetes in of mother
high level of glucose in fetes , thus high levels of insulin - when the umbilical cord gets cut the source of glucose is gone however the insulin levels are still high and need some time to decrease
decreased gluconeogensisis - adrenal insuffieicneecy , errors of metabolism , glycogen storage disease
increased glucose use - hyperthermia , polycethmia , spespsis, hypoxia
how is hypoglycaemia diagnosed ?
heel prick and blood analysis
what is the clinical management go hypoglycaemia ?
dextrose gel applied directly to infant’s mouth / intravenous infusion of glucose
less severe - beast feeding regularly
Jaundice presenting in the first 24 hours of life is more likely to have a serious underlying cause such as ?
infection, haemolytic disease or metabolic disorder
