Ch 10 - Neonatal medicine Flashcards
What is Hypoxic-ischaemic encephalopathy (HIE)
Perinatal asphyxia due to either placental or pulmonary dysfuction/comprimise resulting in brain damage
Causes of HIE (7)
Most cases happen during labour/delivery!
The following are due to reduced gas exchange from placenta: excessive/prolonged uterine contractions
placental abruption
uterine rupture
Interuption of umbilical flow: cord compression, shoulder dystocia, cord prolapse
Inadequate maternal placental perfusion: materal hypo/hypertension - usually causes IUGR as well
Failure of cardiopulmonary adaptation at birth i.e. failure to breathe
Clinical features of HIE can be mild/moderate or severe, give clinical features of mild HIE (3)
irritable, excessive response to stim
hyperventilation
staring of eyes + poor feeding
Clinical features of HIE can be mild/moderate or severe, give clinical features of moderate HIE (2)
marked ABNORMALITIES of TONE & MOVEMENT
no feeding
may have seizures
Clinical features of HIE can be mild/moderate or severe, give clinical features of severe HIE (4)
no response to pain or spontaneous movements
PROLONGED seizures - refractory to treatment
MULTI ORGAN failure
tone - fluctuate between hypo&hypertonia
Management of HIE (4)
Resp support + treatment of seizures
Fluid restrict (because of transiet renal impairment)
Treat hypotension with inotropes
Mild hypothermia within 6hrs of birth reduces brai damage (34 C for 3 days)
Prognosis of mild, moderate & severe HIE
Mild - complete
moderate - excellent for those who have recovered neurologicallyby 14 days (i.e. normal neuro exam) + feeding normally
severe - 30-40% mortality, > 80% of survivors will have neuro impairment - cerbral palsy
Give 3 examples of soft tissue birth injuries
Caput succedaeum
Cephalhaematoma
Chignon
Describe Caput succedaneum (2)
bruisig + oedema of presenting part, extending beyond margins of skull bones
resolves in few days
Describe cephalhaematoma (3)
haematoma from bleeding below periosteum
confined within margins of skull sutures
usually involves PARIETAL bone
centre of haematoma feels soft - resolves i few weeks
Describe a Chignon (2)
Oedema + bruising;
following ventouse delivery
Erb’s palsy definition(1) & causes(2)
upper brachial plexus injury (C5-6);
due to shoulder dystocia or breech delivery
Erb’s palsy features(3) & management
‘waiter’s tip’ i.e. hand internally rotated + pronated + flexed wrist
deltoid, biceps + brachialis paralysis + atrophy
loss of sensation in arm
manage - if doesnt selve resolve in 2 months refer
Facial nerve palsy: Cause, features (2), management
compression of facial nerve against mother’s ischail spine
features - facial weakness on crying + eye stays open
management - it usually is transient; may require methylcellulose drops for eye (lubricant)
Common fractures of neonates (2)
Clavicle - due to shoulder dystocia
Humerus/ femur - breech/ shoulder dystocia
both heal rapidly with mobilization
Respiratory distress syndrome: defintion
AKA hyaline membrane disease (because of the proteinaceous exudate seen in the airways on histology)
Definition - respiratory distress due to lack of surfactant (which functions to lower surface tension - prevent small alveoli collapse)
Respiratory distress syndrome: causes of surfactant def (4)
Pre-term - usually if before 28 weeks Sepsis Diabetic mother elective cs 2nd twin/ male
Respiratory distress syndrome: features (4)
Tachpnoea > 60 bpm
chest wall recession
nasal flaring
ground glass lung appearance (on CxR) + indistinct heart border
Respiratory distress syndrome: prevention/management (2)
corticosteroids antenatally - stimulates surfactant production
surfactant therapy
Pneumothorax - pathophysiology in pre-term infants with RDS
Overdistended alveoli (due to positive pressure O2 therapy) > some air enters intersitium = PIE (pulmonary interstitial emphysema) > air leaks in to pleural cavity
Pneumothorax - features (2) & Ix (1)
Features - Silent Chest with reduced movements on affected side
Ix - transillumination with bright fibre optic light source applied to CW
Pneumothorax - prevention & treatment
Prevent via low pressure ventilation
Treat if tension pneumothorax with chest drain
Bronchopulmonary dysplasia: defintion, causes (3), features (2), treatment (2)
D - infants who still have O2 requirement after 36 weeks
C - the lung damage comes from ventilation trauma, O2 toxicity & infection
F - Wide spread areas of opacification +/- cystic changes
T - CPAP, steroids
Apnoea and bradycardia and desaturation: causes (4), treatment (2)
Cause - mostly because of immaturity of central resp control. However must exclude hypoxia, anemia, infection, hypoglycaemia etc.
Treatment - caffeine, CPAP
Pre-term brain injuries: cause (1 & give common location)
Haemorrhages (occur in v. low BW infants) easily recognized on US. (usually occur in germinal matrix above the caudate nucleus - contains a fragile network of blood vessels) - within 72 hrs of life
Complications of pre-term brain injuries (2)
Hydrocephalus (if large intraventricular haemorrhage impairs drainage of CSF). In this case may require ventriculoperitoneal shunt (after symptomatic relief e.g. LP/ventricular tap) Periventricular leukomalacia (loss of white matter) - will see BILATERAL CYSTS on US
Necrotising enterocolitis - what is it? who is at risk?
Affects pre-term infants in 1st few weeks of life.
Associated with bacterial invasion of ischaemic bowel
Risk - preterm infants fed cow’s milk formula
Necrotising enterocolitis: features (3) x-ray characteristics
Infant stops tolerating feeds, get milk aspiration; billous vomiting; distended abdomen; can get bloody stool;
x-ray: air under diaphragm if perf, distended bowel loops, air in portal tract
Necrotising enterocolitis: management (2)
stop oral feed
Broad spectrum ABs
parenteral nutrition
Retinopathy of prematurity: what is it? cause? treatment?
ROP affects developing blood vessels at junction of vascular and non-vascularized retina. It results in vascular prolif which can cause retinal detachment, fibrosis & blindness.
Cause - O2 tox
Treatment - laser therapy
Why are Preterm infants especially vulnerable to hypothermia? (4) How to prevent it? (1)
High surface area to mass ratio Very little subcut fat Very thin + heat permeable skin Often nursed naked & cannot curl/shiver to generate heat INCUBATE
Patent ductus arteriosus: features (3)
Pulses are ‘bounding’ (from an increased pulse pressure)
Prominent precordial impulse
systolic murmur (“machinery” like)
Treatment of Patent ductus arteriosus (1)
Prostaglandin synthetase inhibitor e.g. ibuprofen/ indometacin (they cause closure of the PDA)
Kernicterus - what is it? features? (4)
Encephalopathy due to deposition of unconjugated BR in basal ganglia + brainstem nuclei (due to saturation of albumin binding capacity)
Features - lethargy, poor feeding, hypertonia, irritability, seizures, coma
Kernicterus - Causes if present
If present haemolyses group A infant), PKD,
Kernicterus - Causes if present between 2 & 14 days of life (4)
Physiological - adaptation to transition from fetal life
Breast milk - more common + prolonged in breast-fed infants (unconjugated)
Dehydration e.g. if delay in establishing breast feeding
Infection - would develop unconjugated bilirubinaemia from poor fluid intake, haemolysis + reduced hepatic function. This is particularly true of UTIs
Other - Crigler-Najjar syndrome - absence of glucouronyl transferase
Kernicterus - Causes if present > 2 weeks post life (conjugated (2) unconjugated (2))
Persistent/prolonged jaundice if > 2 weeks of life
BILIARY ATRESIA - main thing to exclude. it gives a CONJUGATED bilirubinaemia (dark urine + pale stools)
other causes of conjugated e.g. neonatal hepatitis syndrome (A1AT def, infection)
Most common cause is unconjugated bilirubinaemia: due to breast-milk jaundice (disappears by 5 weeks of age), UTI, hypothyrdoisim
Jaundice management (2)
Depends on severity (clinically jaundiced > 80 umol/l)
Gestation - pre-term infants more susceptible to damage so treatment threshold is lower
Management:
Phototherapy - 450nm light converts unconjugated Br to harmless pigment excreted in urine (AE - rash + bronze discoloration)
Exchange transfusion - if Br v. high, blood removed and replaced with donor blood
Respiratory distress in term infant: signs (5)
nasal flaring tachypnoea > 60/min recession tracheal tug expiratory grunting cyanosis
Respiratory distress in term infant: transient tachypnoea of new born - what is it? CxR will show (1), management (1)
commonest cause, due to delay in resorption of lung liquid (more common post C-section)
CxR - fluid in horizontal fissure
Manage - O2 maybe, self-resolving usually
Respiratory distress in term infant: meconium aspiration: complications (3), features (3), management (1)
Meconium may be response to fetal hypoxia
Complications - at birth infants may inhale thick meconium > obstruction + chemical pnuemonitis + predisposing to infection
Features - over-inflated lungs, patches of collapse + consolidation, lung field ‘white out’, can get pneumothorax
managment - artificial ventilation
Respiratory distress in term infant: pneumonia- predispositions (3), management (1)
Predisposed by PROM, chorioamnionitis + low BW
manage - broad spectrum ABs
Respiratory distress in term infant : pneumothorax causes (3)
Meconium
Ventilation
RDS
Respiratory distress in term infant: persistent pulmonary HTN of new born: associations (3), features (4), management (3)
lifethreatining condition associated with:
birth asphyxia, meconium aspiration, RDS, septicaemia
Features - cyanosis, murmur, right to left shunting, pulmonary oligaemia (reduction in blood vol of pulmonary circ)
management - artificial ventilation, inhaled NO, sildenafil
Diaphragmatic hernia: Presentation (1), which side usually? (1) features (2)
Presents with failure to respond to resusc or resp distress
Usually a left sided herniation via posterolateral foramen of diaphragm
Features - displacement of apex beat + heart sounds to right, poor entry in left side
Diaphragmatic hernia: management (2), main complication (1)
Pass large NG tube and apply suction to prevent distension of intracthoracic bowel. Once stable surgical repair of diaphragmatic hernia
Complication - main thing is pulmonary hypoplasia - basically the herniated viscera compresses the lungs and prevents their development (in utero)
Early onset infection (
Usually due to vaginal/ in utero infection (risk increased if PROM/chorioamnionitis)
Presentation - RDS, temp instability
Treat - ABs immediately
Late onset infection (>48hrs): RFs (3), most common pathogen(1), treatment (2)
Usually due to environment e.g. venous catheters, invasive procedures, tracheal tubes,
Most common pathogen - staph epidermidis
Treatment - immediate Fluocloxacillin + gentamicin
Neonatal meningitis: presentation (2) + treatment (1)
Bulging fontanelle + neck/back hyperextension
Treat with Cefotaxime
GBS: Percentage of women carrying it in vag/faeces (1), RFs for infection (3), treatment (1)
10-30%
PROM/ chorioamnionitis/ intrapartum fever
Treat - prophylactic IV AB
Listeria monocytogenes infection: RFs (2), complications (3), features (3), Treatment (1)
unpasterurized milk/soft cheese/ poultry
may result in - spontaenous abortion/ pre-term delivery or neonatal sepsis
Features - meconium staining of liquor, widespread rash, pneumonia + meningitis (30% mortalitity)
Treatment - ampicillin
Gram-ve infections - source (1), treatment (2)
usually from central venous lines
treat with Tazocin or gentamicin
Neonatal conjunctivitis (opthalmia neonatorum): causative pathogens(4). Typical presentation (2)
Gonococcal/chlamydia/HSV-2/S. Aureus/ S. pneumonia
Notifiable disease
Sticky + red eyes on day 3/4
treatment of most can be via saline or neomycin (topical AB)
Presentation (2) & Management of gonococcal conjunctivitis (1)
Purulent discharge + conjunctival injection + eyelid swelling
IV Cefotaxime
Presentation (2) & management of staphylococcal conjunctivitis (1)
Purulent discharge + eyelid swelling
PO erythromycin for 2 weeks
Umbilical infection - management of inflammation (1) & granuloma (1)
Systemic ABs
Silver nitrate
HSV Transmission (2) presentation (2), treatment (1)
Usually via birth canal, sometimes ascending infection
Presentation: can be localised - herpectic lesions on skin & eye. Or disseminated - encephalitis
treat - Aciclovir
Hep B infection management
Give both mother and infant Hep B vaccine
Neonatal hypoglycaemia: definition (1), causes (4), features (3), Prevention (1), management (2)
D -
Neonatal seizures: causes (6) management (2)
HIE, stroke, metabolic - hypoglycaemia/calcaemia/natreimia, increased ICP, meningitis, kernicterus (1st rule out hypoglyacemia & meningitis)
Treat the cause & anticonvulsants for prolonged seizures
Neonatal stroke: prognosis
only 20% have hemiparesis/ epilepsy later in childhood
Define cleft lip
Failure of fusion of frontonasal & maxillary proceesses
Define Cleft palate
failure of fusion of palatine processes + nasal septum
Complications of cleft lip/palate (2)
feeding difficulties - choking & coughing; acute otitis media
Pierre robin sequence: triad (3), complications(3), management (2)
Small jaw (micrognathia) + posterior displacement of tongue + midline cleft of soft palate Complications: feeding difficulties + obstruction (due to tongue - cyanotic episodes), failure to thrive M - self resolves usually, nasopharyngeal airway
Oesophageal atresia: Features (3), associations (VACTERL)
if suspected a tube is passed and checked by x-ray to see if it reaches oesophagus
Features - salivation/drooling, cyanotic episodes, aspiration
Assocations - polyhydramnios, tracheo-oesophageal fistula. These babies often have other congenital malformations as part of the VACTERL association( Vertebral, Anorectal, Cardiac, Tracheo-Esophageal, Renal, radial Limb)
SBO: features (1), causes (5)
F - Billous vomiting (unless above ampulla of vater)
Causes:
Duodenal atresia/ stenosis: on axr will see ‘double bubble’ due to stomach distension & duodenal cap on both sides of diaphragm
Jejunal/ileal atresia/stenosis - surgical treatment
malrotation with volvulus - can lead to midgut infarction!
meconium ileus - thick sticky meconium impacted in lower ileum (almost all affected have CF)
Meconium plug - lower intestinal obstruction - spontaneous passing
Large bowel obstruction: causes (2)
Hirschprung’s disease - absence of myenteric nerve plexus> no meconium passed in 48hrs > abdo distension
Rectal atresia - absence of anus at normal site. Can be a ‘high lesion’ - bowel ends above levator ani muscles
‘low lesion’ - bowel ends below levator ani muscles
What is an exomphalos
Abdo contents protrude through umbilical ring. Contents covered by amniotic sac + peritoneum.
what is a gastroschisis
Bowel protrudes through defect anterior abdo wall - not covered in any peritoneum - higher risk of dehydration + protein loss.
