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Neonate > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

phases of fetal development

A

pre-embryonic
embryonic
fetal

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2
Q

pre-embryonic phase

A

conceptus (blastocyst) migrates from fallopian tube to uterus

  • time from fertilization to implantation
  • typically 8 days
  • independent of environment (not of genetics)
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3
Q

embryonic phase

A

weeks 3-8

  • period of organogenesis
  • germinal tissues form
  • heart starts to beat (6 weeks)
  • time when malformations occur
  • greatest vulnerability to teratogens
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4
Q

fetal phase

A

9 weeks - delivery

- further growth, differentiation, and maturation of organs

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5
Q

in fetus, when do pulmonary alveoli begin to develop?

A

24 weeks - this is earliest fetus is viable outside of womb (baby will be on ventilation)

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6
Q

in fetus, when does surfactant present in lungs?

A

34 weeks - baby can breath on own (alveoli pop open and stay open upon first breath)

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7
Q

organogenesis

A

time when all of the tissues are specializing and organs are forming

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8
Q

germinal tissues

A

3 cell layers form:

  • ectoderm will become skin and nervous system
  • mesoderm will become muscle and bone
  • endoderrm will become GI tract (alimentary canal), endocrine and respiratory systems
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9
Q

membranes around fetus

A

amnion - inner layer
chorion - outer layer

these begin as separate sacs and fuse; contain amniotic fluid

function: protect fetus from injury and infection

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10
Q

membranes ruptured vs. membranes intact - acronyms

A

PROM: prolonged rupture of membranes (rupture prior to 18 hours b/f delivery)
- inc risk of infection

PPROM: premature, prolonged ROM (rupture prior to 35 weeks gestation)

SROM: spontaneous ROM (happens on own)

AROM: artificial ROM (OB or midwife ruptures membranes)
- facilitates monitoring; increases force of contractions

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11
Q

amniotic fluid - definition and functions

A

watery fluid derived mainly form maternal blood

Functions:

  • acts as a cushion for fetus as mother moves
  • prevents membranes from sticking to baby
  • allows for fetal movement
  • necessary for lung development
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12
Q

what is the placenta and what is it made up of

A

It is the site of exchange of materials in both directions; acts as the intermediary between the fetus and the outside world

chorionic villi (from fetus) and decide baseless (from mother)

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13
Q

chorionic villi

A

fetal contribution to placenta

finger-like projections of chorion which penetrate into the endometrium, the lining of the uterus.

each contains fetal arteriole, venule and capillary

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14
Q

decidua basalis

A

maternal contribution to placenta

when chorionic villus invades the endometrium, it causes the maternal capillary beds to break down into sinusoids
- arteriole –> open space –> venule

fetal capillary sits within the sinusoid and is bathed by maternal blood

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15
Q

crossing the placenta

A

diffusion of molecules in either direction

Mother to fetus: oxygen, aminio acids, fats, glucose, some hormones, antibodies, most drugs, viruses

Fetus to mother: carbon dioxide, bilirubin, ammonia and other waste products

note: cells and large molecules are unable to pass

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16
Q

human chorionic gonadotropin (hCG)

A

a hormone which, along with progesterone, maintains the lush endometrium necessary to sustain pregnancy

produced by placenta

by the end of the second week post-conception, present in sufficient quantity to be detected by assay in maternal blood and urine
- basis for pregnancy tests

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17
Q

when does ovulation occur?

A

Ovulation occurs 14 days before menstruation.

Standard cycle length is 28 days; therefore, in standard situation, ovulation is mid-cycle

In longer cycles, ovulations still occurs 14 days before menses, so toward latter part of cycle

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18
Q

how to date a pregnancy

A

counting 40 weeks from first day of last menstrual period
- E.D.D. = estimated date of delivery (unreliable for many reasons: recall, cycle length, implantation bleeding)

  • notice that the first two weeks of pregnancy actually occur before ovulation and fertilization!
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19
Q

role of ultrasound in pregnancy

A

Dating pregnancy
Evaluating anatomy
Checking position of placenta
Checking volume of amniotic fluid (indicator of kidney and resp. health)

two types:

  • transvaginal
  • transabdominal
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20
Q

transvaginal ultrasound

A

Ultrasound probe is inserted into vagina

  • useful early on in pregnancy because can get closer to fetus and give more accurate images in first weeks
  • disadvantages: can be uncomfortable for mom
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21
Q

transabdominal ultrasound

A

Easy to perform
Standard technique
More comfortable
Works best when baby is a bit bigger and bowel is out of way

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22
Q

accuracy of ultrasound dating - depends on when it is done

A

First trimester: measure crown-rump length
- accurate +/- 3 days

Second trimester: measure biparietal diameter
- accurate +/- 1 week

Third trimester: biparietal diameter (across top of head)
- accurate to +/- 2 weeks

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23
Q

definition of trimesters

A

First trimester: weeks 1 to 12 (13 wks)

Second trimester: weeks 13 to 28 (16 wks)

Third trimester: weeks 29 to delivery (11 wks)

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24
Q

definition of “term” pregnancy

A

38-42 weeks

37 weeks – consider no risk

42 weeks – baby gets big; placenta begins to die off

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25
Q

importance of blood type / antibody screening

A

maternal antibodies can cross the placenta

mismatch between maternal and fetal blood types can cause situation where mother makes antibody to fetus’ blood cells

result is hemolysis (destruction) of fetus’ RBCs
- causes jaundice and in extreme, total body edema, a condition known as “hydrops fetalis”

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26
Q

ultrasound for anatomic survey

A

checks babies anatomy

- best b/t 18-20 weeks since all organs have formed but baby is not too large

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27
Q

why perform genetic screening?

A

Advanced maternal age (35)

Abnormal findings on prenatal ultrasound

Family history of genetic disorder

Previous miscarriages

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28
Q

two ways of genetic screening

A

Amniocentesis: sample of amniotic fluid via insertion of needle into chorionic sac

Chorionic villus sampling: get sample of chorionic sac
- farther from baby, so safer, but only can do for a specific time period

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29
Q

glucose tolerance test - done since mom’s can get type II diabetes during pregnancy and insulting is a growth factor for babies

A

Test to assess for maternal diabetes

  • fasting blood sugar provides a baseline for comparing other glucose values; pregnant women drink 75 grams of glucose; blood samples will be collected at timed intervals of 1 and 3 hours after patient drinks the glucose.
  • elevated blood sugars prompt various treatments: dietary management, oral hypoglycemic agents, insulin

Performed at 16 weeks

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30
Q

infection diseases: what and when tested

A

First prenatal visit: Screens for: Hepatitis B, HIV, Syphilis, Gonorrhea, Chladymia.
-may repeat prior to delivery in high-risk individuals

Screen for immunity to Rubella, usually conferred by vaccine

Group B strep screening at 36 to 37 weeks

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31
Q

routine testing of mother (and mothers of specific decent)

A

Alpha fetoprotein:

  • high in neural tube defects
  • low in Down Syndrome

Specific to population:

  • sickle cell disease
  • cystic fibrosis
  • “Ashchkinasi screen” for diseases found in people of European Jewish descent
  • specific to family, based upon family history
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32
Q

malformations

A

complete or partial absences of a structure caused by environmental or genetic factors

  • most originate during the period of organogenesis (3rd to 8th weeks of gestation)
  • e.g. congenital heart defect
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33
Q

Tetralogy of Fallot

A

MOST COMMON CYANOTIC CHD

A set of congenital cardiac defects including:

  • overriding of ascending aorta over ventricular septum and receives venous as well as arterial blood (due to hole in septum)
  • ventricular septal defect
  • pulmonic valve stenosis (obstruction of RV outflow) - valve is pushed over and compromised
  • right ventricular hypertrophy due to inc. pressure since blood can’t get through valve; considered part of the tetralogy although it is reactive to the other defects (syn: Fallot tetrad)

Note: degree of cyanosis depends on degree of stenosis of the pulmonic valve

Note: “boot-shaped” heart

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34
Q

deformations

A

due to mechanical forces that mold a previously normal part of the fetus over a prolonged period

  • often musculoskeletal and reversible
  • occurs during fetal period (after 9 weeks)
  • e.g. clubfoot
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35
Q

disruptions

A

destructive processes which result in morphological alterations of already formed structures

  • e.g. limb defects caused by amniotic bands
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36
Q

syndromes

A

groups of anomalies occurring together which have a common cause
- e.g. Stigmata of Down Syndrome are caused by trisomy of chromosome 21

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37
Q

associations

A

groups of anomalies that occur together more often than chance alone would allow but whose cause has not been determined
- e.g. CHARGE association (coloboma, heart defects, atresia choane, retardation of growth and development, genital abnormalities, ear abnormalities)

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38
Q

teratogens

A

agents, generally chemical, radioactive or infectious which can produce birth defects. - especially destructive when exposure occurs during the period of organogenesis (i.e. embryonic period)

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39
Q

important influences on pregnancy outcomes - obesity and malnutrition

A

obesity (BMI>30): infants of obese women have birth weights equal to those of non-obese women but have 30% more body fat, at expense of lean body mass

malnutrition: causes lifelong immunodeficiency, short stature, cognitive impairment; most common cause of low birth weigh babies in developing world

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40
Q

key vitamins and minerals during pregnancy

A

Folic acid: a B-complex vitamin which can reduce the risk of neural tube defects by 70%
Calcium: for bones, teeth, muscle, CNS
Iron: for development of blood cells, CNS
Vitamin D: for bones and teeth
- currently being touted as a panacea– e.g. improved immunity
Vitamin A:
important for development of eyes
- excess can cause major malformations as with isotretinoin (Accutane)

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41
Q

diabetes mallitus (DM) in pregnancy

A

relative or absolute deficiency of insulin secretion which results in hyperglycemia in mother - all 3 types (gestational, type I, and type II have same effect on fetus)

  • Insulin does not cross the placenta
  • Glucose diffuses freely across the placenta
  • baby makes a lot of insulin to regulate high glucose load
  • insulin acts as a powerful growth hormone in fetus, causing macrosomia
  • excessive insulin results in risk of hypoglycemia in the newborn period
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42
Q

macrosomia

A

large growth of fetus; caused by large levels of insulin which acts as a growth hormone for fetus

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43
Q

effects of excessive glucose in 1st trimester

A

teratogenic - can cause caudal regression syndromes (malformations of hips & legs)

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44
Q

effects of thyroid disease on fetus

A

Hyperthyroidism in mom is usually Grave’s disease, a condition in which mom makes an antibody which stimulates thyroid hormone production
- can cause growth retardation or prematurity in newborn

Hypothyroidism

  • treated, does not affect the fetus (synthroid)
  • untreated, can cause decreased IQ, small stature
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45
Q

hypertension (HNT)

A

can predate pregnancy or be pregnancy-induced (PIH)

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46
Q

pre-eclampsia

A

HTN (hypertension) which generally begins third trimester and is associated with edema (maternal) and proteinuria

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47
Q

eclampsia

A

same features as pre-eclampsia with addition of maternal seizures

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48
Q

HELLP syndrome

A

severe form of HTN associated with hemolysis, elevated liver enzymes, low platelets

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49
Q

risks of HTN to mom and baby

A

mom: stroke
baby: primarily related to insufficient blood supply to the placenta (because of vasoconstriction)
- IUGR (intrauterine growth restriction)
- premature delivery

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50
Q

risks of extreme youth pregnancy

A

defined as

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51
Q

risks of advanced maternal age pregnancy

A

defined as > 35 yrs; risks inc with age
- Down Syndrome

Note: CHD much more likely in babies with Down Syndrome - all Down Syndrome baby’s get echocardiograms!

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52
Q

medications used by mother

A

as a rule, they cross placenta

if possible, stop all prior to conception

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53
Q

risks of anticonvulsants used by mom - 20-35% of woman with seizure disorders have an increase in seizures during pregnancy

A

Dilantin (phenytoin) is associated with “fetal hydantoin syndrome”, consisting of cleft lip and palate as well as mental retardation

Valproic acid is associated with neural tube defects (eg. Spina bifida)

Keppra has had limited study but no teratogenicity

Lamictal .9% (8.9/1000) incidence of cleft lip +/- palate

54
Q

risks of psychotropic medications used by mom

A

Lithium, used to treat bipolar illness, risk of Ebstein anomaly (displacement of tricuspid valve into right ventricle)

Phenothiazines, older anti-psychotic meds (eg, Haldol and Thorazine) had no known teratogenic effects but had disagreeable side-effects for the adult patient

Newer antipsychotics’ effects are unknown but they certainly cross the placenta (e.g. Seroquel)

SSRIs antidepressants which are currently first-line

55
Q

risks of antidepressant use by mom - pregnancy can increase depression, so not best time to stop medication use

A

Tricyclics: amitriptyline and nortriptyline are older and known to be safe

Selective Serotonin Uptake Inhibitors (SSRI): fairly safe

  • Celexa, Prozac, Zoloft all safe
  • Avoid Paxil- doubles risk of septal defects in fetus
  • Wellbutrin: OK
56
Q

risks of general anesthesia, surgery, and x-rays during pregnency

A

General anesthesia: not teratogenic

Surgery: can be safely performed on MOC during pregnancy

XRays: known to cause microcephaly, spina bifida, cleft palate, and limb defects

57
Q

risks of tobacco use by mom

A

IUGR: most common cause of IUGR in developed contries

spontaneous abortion
prematurity
perinatal mortality
SIDS

58
Q

risks of marijuana use by mom

A

associated with IUGR

long-term side effects controversial: may cause measurable cognitive impairment

mild neurological abnormalities (jitteriness and irritability as newborn)

59
Q

risks of opiate use by mom (includes narcotics)

A

This group of drugs includes narcotics

  • Prescription: fentanyl, oxycodone, methadone, morphine
  • Non-prescription: heroin

Acute intoxication at delivery can cause respiratory suppression

Babies are likely to be born dependent and exhibit signs and symptoms of withdrawal, requiring methadone taper

60
Q

risks of cocaine use by mom

A

prematurity, among many other things (mainly cognitive and behavioral problems, but no motor defects)

61
Q

risks of amphetamine (meth) use by mom

A

microcephaly, cleft lip and palate

most prevalent problem = neglect

62
Q

risks of alcohol use by mom - 3 major components of fetal alcohol syndrome

A

Prenatal and postnatal growth deficiencies

Microcephaly associated with cognitive impairment

Typical facies: short palpebral fissures, indistinct philtrum, thin upper lip

63
Q

APGAR Score

A

reported 1 and 5 minutes after birth; most effective for term babies; expression of infant’s physiological condition and includes subjective components

A: appearance

  • blue or pale = 0
  • acrocyanotic (hands, lips blue) = 1
  • pink = 2

P: pulse (HR) 80-160 BPM

  • absent = 0
  • 100 = 2

G: grimace / reflex irritability (responce to stimulation)

  • none = 0
  • weak response to rub = 1
  • active withdrawal or cry = 2

A: activity (tone)

  • limp = 0
  • some flexion = 1
  • active motion = 2

R: respiratory, 30-60 breaths/min

  • absent = 0
  • weak cry/hypoventilation = 1
  • good, crying = 2
64
Q

labor

A

process by which products of conception (baby, placenta, cord and membranes) are expelled from the uterus

  • requires thinning and dilation of cervix, resulting from rhythmic contractors of uterine muscles
  • note: contractions w/o cervical changes does not meet definition of labor
65
Q

changes in labor definitions (2014) to limit c-sections

A

allowing most women with low-risk pregnancies to spend more time in the latent or early phase of the 1st stage of labor
- changing the definition of active labor to start at 6 cm.

allow for more time in the second stage or pushing stage of labor
- first time Mom’s are now routinely able to push for 3 or more hours before the second stage is considered prolonged

66
Q

normal HR for fetus - fetal monitoring

A

HR: 120-160 (done with internal monitor in baby’s scalp - tells us membranes have been ruptured)

1st stage of labor: fetal HR increases with contractions

second stage of labor: fetal HR decreases with contractions (due to head compression and stimulation of vagus nerve)

note: deceleration of HR after contractions are abnormal and indicate stress on fetus

67
Q

epidural

A

goal is to provide analgesia not anesthesia

risks: short-term backache, puncture headache, hypotension, maternal fever, prolonged labor, and increased rate of instrumental delivery
- do not increase a mother’s risk of delivering by cesarean
- current recommendations: placement of epidural at maternal request regardless of cervical dilatation.

68
Q

EnCaul

A

baby delivered with membranes intact

69
Q

three types of operative delivery and risks of each

A

Cesarean section: - retained lung fluid

  • laceration of the fetus
  • surgical complications
  • prolonged recovery for mom

Forceps assisted birth:

  • skull fractures (rare)
  • facial nerve palsy (heals quickly / good prognosis)

Vacuum assisted delivery: shearing forces on the scalp
- subgaleal hemorrhage: large potential space where baby can bleed out (extradural hemorrhage) - why we say these can be dangerous (shock)

  • cephalohematoma: collection of blood within periosteum; blood does not cross suture lines (can also get from pounding)
  • caput: edema (fluid filled area of scalp; fluid will move with changes in position)
  • damage to skin
70
Q

birth positions

A 
occiput anterior (OA): head first, face down
 - most common
occiput posterior (OP): head first, face up; largest surface area of the skull presents
  - more likely to need operative intervention

transverse lie: baby is sideways
- incompatible with vaginal delivery

breech: buttocks are delivered before the head

71
Q

recommendations for babies in breech position

A

dependent on experience of health care provider (c-section will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery)

Obstetricians should offer and perform external cephalic version
- attempt to turn baby by manipulating fetus from outside of mom’s abdomen

72
Q

transitional period for newborn

A

first few hours after birth; period of many changes in the physiological makeup of the newborn, including conversion of cardiac and pulmonary systems to extrauterine life

73
Q

normal newborn vital signs

A

Temperature: 36.5-37.5°C (axillary)

Heart rate: 120-160 beats/min

Respiratory rate: 30-60 breaths/min

Blood pressure: 60/40 (rarely take in newborn)

74
Q

periodic breathing of infants

A

infants exhibit periodic breathing or bursts of rapid breaths, slowing, then rests for

75
Q

preventative care of newborn: medications and vaccination

A

3 interventions given within 2 hours of birth (eyes and thighs):

  1. Eye prophylaxis with 0.5% erythromycin ophthalmic ointment
    - helps to prevent gonorrhea (good) and chlamydia (so, so)
  2. Hepatitis B Vaccine (mom can decline)
  3. Vitamin K: 1 mg IM (orally)
    - prophylaxis against early and late Vitamin K Deficiency Bleeding (VKDB)
76
Q

definition of neonate

A

period of birth to 28 days old

77
Q

anatomy of heart

A

4 chambers
2 upper are atria (singular atrium)
2 lower are ventricles

Septa (singular: septum) are muscular walls which divide the sides

4 valves:
Tricuspid: between the right atrium and right ventricle
Pulmonary: between right ventricle and pulmonary artery
Mitral: between left atrium and left ventricle
Aortic valve: between left ventricle and aorta

Major vessels:
Inferior and Superior Vena Cava: largest veins in body, bring blood back from systemic circulation to right atrium & then ventricle
Pulmonary artery: takes deoxygenated blood from right ventricle to lungs- note branches
Pulmonary veins: return oxygenated blood from lungs to left atrium
Aorta: takes oxygenated blood to systemic circulation

78
Q

neonatal circulatory shunts

A

Since fetus does not use lungs to breath, shunts take blood away from lungs to placenta; shut off upon birth

Note: pressure on right side is higher in fetus

Ductus arteriosus: shunt between pulmonary artery & aorta, has no valves so blood can flow each direction

Umbilical arteries: branches of common iliac arteries that take blood to placenta

Umbilical vein: from placenta to liver or DV

Ductus venosus (DV): option to bypass liver, direct to IVC since placenta filters blood

Foramen ovale: interatrial shunt from RA to LA

Functional shunt: increased pulmonary pressure so most blood goes to body and not lungs (10-20% to lungs) - rt sided pressures are higher than lt sided pressures

79
Q

how shunts are shut off at birth

A

Umbilical arteries are cut at birth, which cut supply to umbilical veins and ductus venosus

Ductus arteriosus closes within 24-48 hours due to increased in PO2 and decrease in prostiglandins

Foramen ovale is shut off due to pressure change (pressure increases on left side)

80
Q

partial pressure of oxygen

A

partial pressure of any gas is a measurement of how much gas there is in any environment (e.g. liquid, room of air)

  • changes with altitude
  • changes in fetal lung during transition
81
Q

percent saturation

A

% saturation of oxygen in air is 21% regardless of altitude
- the number of molecules of oxygen are fewer as altitude increases but the percentage of oxygen molecules to total molecules in air is always 21%

% saturation of oxygen in blood - percentage of red blood cells are carrying oxygen

  • measured by a pulse oximeter
  • this can change with blood
82
Q

percent saturation after transition

A

should be greater than 95%

83
Q

how can you trust you have an accurate pulse Ox reading

A

wave-forms on machine and pulse matches the one you took

84
Q

pressure changes during transition and effects on shunts

A

Increase in pO2 in blood when baby begins to breathe air

  • dilatation of vessels in pulmonary bed drops pulmonary pressures; therefore, right sided pressures become lower than left (functional shunt gone)
  • constriction (closure) of ductus arteriosus

Systemic pressure increases as a result of cutting off umbilical circulation (to and from placenta) with result of increased volume elsewhere

Foramen ovale: pressure effect of having LA pressures greater than RA pressure

Ductus venosus closes because there is no longer flow through it

85
Q

cardiac cycle

A

Systole

  • time from onset of ventricular contraction until closure of aortic and pulmonary valves
  • begins with first heart sound- closure of tricuspid and mitral valves

Diastole

  • time of filling of chambers
  • time between second and first heart sounds
86
Q

congenital heart disease (CHD) - types

A

most common congenital malformation in newborns with at least 35 variations

Critical congenital heart disease: requires intervention in first 28 days

Serious congenital heart disease: requires intervention in 1st year

87
Q

how does CHD present in a newborn

A

Although there are a variety of possible lesions, CHD presents in only a few ways:

  • Cyanosis
  • Heart failure (or its extreme, shock)
  • Cardiac murmur
88
Q

cyanosis in newborn - two types

A

central: lips, inside of mouth / mucous membranes, chest
- serious; most don’t notice cyanosis until pulse ox is low (84)

acral: fingers, toes, perioral
- not serious; reflects perfusion rather than oxygenation

89
Q

two cardiac-related (CHD) causes of central cyanosis

A

Decreased pulmonary blood flow caused by improper closing of shunt

Mixing of oxygenated and deoxygenated blood in heart (fixed mixing lesions)

90
Q

cyanosis - main causes

A

Primary lung diseases such as pneumonia, respiratory distress syndrome, meconium aspiration, etc.

Airway obstruction

Hypoventilation (drug induced or neurologic)

Polycythemia

Congenital heart disease

91
Q

cyanosis: pulmonary vs. cardiac

A

pulmonary:

  • labored breathing
  • improves with 100% oxygen supplementation
  • cyanosis often improves with crying

cardiac:

  • non-labored respirations
  • no or minimal response to 100% oxygen
  • cyanosis worsens or doesn’t improve with crying
92
Q

hyperoxitest

A

Most sensitive tool for differentiating between primary pulmonary and cyanotic congenital heart disease

  • measure pO2 by blood gas in room air
  • place baby on 100% oxygen for 10 minutes, then re-check blood gas
  • note: pulse ox often used, easier but less accurate

Results: a patient with primary pulmonary disease will usually dramatically increase saturation when given oxygen; cardiac etiology will have no improvement

93
Q

symptoms of CHF in newborn

A

Increased left atrial pressure causes pulmonary vascular congestion and pulmonary edema

  • tachypnea results from vascular congestion and edema (lungs are stiff and wet)
  • tachycardia results from low cardiac output

Hepatomegaly reflects increased pressure in the right atrium

Sweating and feeding difficulties are common

May be cyanotic or not, depending on degree

94
Q

newborn murmurs and how to describe them

A

cardiac murmurs are very common; must distinguish innocent from pathologic!

Description:

  • intensity
  • timing in systole or diastole
  • quality
  • location
  • transmission
95
Q

how to grade intensity of a cardiac murmur

A

6 point scale

  1. Barely audible
  2. Soft but easily audible
  3. Moderately loud, but without thrill
  4. Louder and associated with a thrill (palpable palpation on chest)
  5. Audible with stethoscope barely on chest
  6. Audible with stethoscope off the chest
96
Q

how to describe quality of murmurs / character of sound

A

Innocent murmurs are described as “vibratory” or “musical”

Ventricular septal defect (VSD) is high-pitched and blowing or coarse
- shows up later since depends on changes in pressure

Aortic stenosis (AS) & Pulmonic stenosis (PS) described as “grating”
 - hear at birth since due to valve defects that are not affected by changes in pressure
97
Q

ejection type murmurs

A

you can distinctly hear S1 (closing of the tricuspid and mitral valves), then the murmur, then S2

caused by flow through stenotic or deformed semilunar valve (aortic or pulmonic)

Also called “crescendo-decrescendo”

98
Q

regurgitant murmurs

A

you can’t separate the murmur from S1

caused by flow of blood from a chamber that is at higher pressure to one of lower pressure - big hole and blood flowing back and forth

(e.g. VSD)

99
Q

benign murmurs (3 common) - common during transition / closing of shunts

A

Pulmonic flow murmur or “peripheral pulmonic stenosis”

Physiologic ductus arteriosus

Tricuspid Jet

100
Q

pulmonary flow murmur - newborn

A

most common / benign

also known as “peripheral pulmonic stenosis” or PPS

101
Q

ways to evaluate newborn

A

fetal echocardiogram: only most severe cases of CHD can be determined (more accurate at 18-20 weeks)
- most useful for congenital heart lesions, but every expensive!

blood pressure (4 limbs): difference b/t rt arm and leg is indication for coarctation of aorta

pulse oximetry (done as screening test; baby can be low on O2 saturation even if color is good)

chest x-ray: useful for signs of CHF (enlarged heart or pulmonary edema)

102
Q

polycythemic (aka erythrocythemia)

A

increase in the total red blood cell mass of the blood

- baby with this disorder looks for cyanotic than an anemic baby at same saturation

103
Q

transposition of great vessels

A

serious condition where aorta comes out of right ventricle and pulmonary vein comes out of left ventricle; thus, un-oxygenated blood in going through body and oxygenated blood in a closed circuit through lungs

  • two independent circuits that do not support life (note: ok in utero, but deadly at birth)
  • note: “egg on a string” shaped heart
104
Q

two types of neonatal CHD

A
  1. Obstruction to the flow of blood in the heart or great vessels caused by underdevelopment of structures

Valves, ventricles, vessels

  • Valvular atresia/stenosis
  • Hypoplastic left or right heart syndromes
  • Coarctation of the aorta/interrupted aortic arch
  1. Blood flows in abnormal patterns

Through septal defects, abnormal communications

  • From right to left (blue mixes with red)-leads to cyanosis
  • From left to right (red mixes with blue)-leads to CHF
105
Q

most common cardiac lesions in newborn (cyanotic vs. acyanotic)

A

Cyanotic - 5 T’s with a P and H

  • Transposition of the great vessels
  • Truncus arteriosus (single arterial vessel arises from heart, instead of separate aorta and pulmonary artery)
  • Tricuspid atresia (absence of tricuspid valve on rt side of heart)
  • Tetralogy of Fallot
  • Total anomalous pulmonary venous return (TAPVR) (pulmonary viens do not empty into LA)
  • Pulmonary atresia / stenosis (passage is closed, narrow, or absent)
  • Hypoplastic left heart

Acyanotic

  • Patent ductus arteriosus
  • Large septal defects
  • Critical aortic stenosis
  • Coarctation of the Aorta
  • Hypoplastic left heart
106
Q

patent ductus arteriosus

A

acyanotic heart lesion; ductus arteriosis, b/t pulmonary artery and aorta, remains open
- blood flows from aorta to pulmonary arteries to lungs = pulmonary edema (due to higher pressure now in aorta)

typically closes within hours to days of birth

most frequent disorder in premature babies

107
Q

ventricular septal defects (VSD)

A

acyanotic heart lesion
MOST COMMON CHD
hole in either atrial or ventricular septum; blood will flow in direction of greatest to least pressure, which changes from fetus to newborn

note:
- if on own, will not present with hypoxia since blood goes form lt to rt and to lungs to get oxygenated
- if part of tetralogy of fallot, this is a mixing lesion that presents with hypoxia

108
Q

longterm risk of un-treated VSD

A

Eisenmenger’s complex: pulmonary vascular disease (hypertension) with continued pulmonary over circulation

109
Q

coarctation of aorta

A

acyanotic lesion - narrow area of aorta results in impaired left ventricle output, decreased pulses, differential BP

Early presenting: when DA closes in few days, drastic presentation of shock, renal failure

  • prostaglandins (IV): temporary life saver (open ductus)
  • requires surgery once baby is stable

Late presenting: around age of 5, patient has weakness/fatigue in legs
- requires surgery, but not emergency

110
Q

basis CHD therapies - summary

A

Prostaglandin E1–keeps ductus arteriosus open
- crucial in left-sided obstructive lesions & lesions with decreased pulmonary blood flow

Diuretics–improve pulmonary edema

Inotropic agents–improve cardiac contractility
- dopamine, dobutamine, digoxin

Oxygen–increases pulmonary blood flow, alveolar oxygen delivery

Catheterization–can open valves, atrial septum with balloon

Surgery–various shunts and repairs

111
Q

normal respirations during transition

A

RR: 40-60
periodic breathing
pO2>85%
- after transition pO2>90%

112
Q

tachypnea

A

increases rate of breathing (> 60 BPM)

MOST SENSITVE INDICATOR OF LOWER AIRWAY DISEASE

  • tachypnea combined with retractions = inc. “work of breathing” - since each breath provides less o2, baby compensates by breathing quickly
113
Q

audible noises - indicating respiratory distress

A

Grunting or Singing

  • low or high-pitched sounds on expiration
  • reflect baby’s attempt to keep air in lungs to prevent collapse

Stridor

  • inspiratory sound
  • obstruction of middle airway
114
Q

auscultory noises -indicating respiratory distress

A

Crackles or rhales

  • inspiratory sounds
  • reflect fluid in the air-spaces
  • rhales: sounds like rubbing hair in front of ears

Wheezing or rhonchi

  • high or low pitched sounds on expiration (inspiration when severe)
  • reflects air trying to escape past obstruction in middle airways
115
Q

percent saturation - acceptable levels at birth / transition

A 
2 min 60%
3 min 70%
4 min 80%
5 min 85%
10 min 90%

All neonates take time to clear lung fluid
- tolerate sats of 85 to 87% for the first few hours of life - if baby is otherwise asymptomatic

116
Q

pulmonary disorders in newborns

A

MOST COMMON cause of respiratory distress in newborns

  1. Upper airway obstruction
  2. Lower airway obstruction
117
Q

upper airway obstruction

A

Nasal stuffiness - newborns are OBLIGATE nose breathers

Choanal Atresia - back of nasal passage blocked
- presents with cyanosis at rest and pink with crying

Masses

Micrognathia (gnath = jaw)

Laryngeal or Tracheal Obstruction (middle airways)
- floppy airway is the MOST COMMON cause of middle airway obstruction

118
Q

lower airway obstruction

A

If suspect lower airway disease, get a CHEST X-RAY

Aspiration - process of drawing breath
- meconium, amniotic fluid, maternal blood

Hyaline membrane disease (aka respiratory distress syndrome)

Pneumothorax - collapse of part or all of lung

TTN (transient tachypnea in newborns) - results from retained fluid in lung (aka RFLLS)
- supportive O2 care for few days

Pneumonia: neonatal systemic infections (bacterial or viral) - group B strep, etc.

119
Q

normal transition in lungs

A

hormonal changes associated with labor cause fluid to begin to be cleared from lungs

Many neonates show some mild respiratory distress immediately after delivery as the clearing of fluid continues.

120
Q

how to read a chest x-ray (CXR)

A

RIP ABCDE

R: rotation (check clavicles)
I: inspiration (9 ribs)
P: penetration (correct amount of x-ray material; should see b/t vertebrae)
A: should see two bronchi splitting from airway
B: fractures of anomalies
C: rt and lt heart borders
D: diaphragm borders should be well-defined
E: everything else (lines, leads, foreign bodies)

121
Q

CXR - newborns highlights

A

Heart: no more than 65% of width of chest

Diaphragm: should see sharp costophrenic angles b/t lung, chest floor, and diaphragm; if not, think pulmonary effusion)

Pulmonary vasculature: fills medial 1/3; if more, think possible heart failure

122
Q

RFLLS

A

retained fetal lung liquid syndrome; resolution of symptoms in 1-5 days
- CXR: “wet silhouette”

123
Q

meconium aspiration syndrome (MAS)

A

NOT COMMON in premature babies

Meconium is present in amniotic fluid in 12% of deliveries

  • of that 12%, 4-6% are complicated by aspiration
  • of that 4-6%, 50% require mechanical ventilation

Usually occurs in term or near term infant

Passage of meconium RARE before 34 wks

124
Q

3 serious outcomes of MAS

A

meconium aspiration syndrome

  1. persistent pulmonary hypertension of newborn - tar-like stuck in lungs
  2. pneumothorax
  3. pneumonia (inflammatory rather than infection)
125
Q

Hyaline Membrane Disease/Respiratory Distress Syndrome (RDS)

A

Occurs almost exclusively in premature infants (

126
Q

Most common cause of growth retardation in developed countries v. developing countries

A

hyperthyroidism (Graves disease) vs. malnutrition

127
Q

Risk to baby of having a mother over 35 v. a mom under 16

A

old: Down Syndrome
young: pregnancy induced hypertension and prematurity

128
Q

what is the most sensitive indicatory of lower airway disease?

A

respiratory rate / tachypnea

129
Q

nuchal cord

A

umbilical cord around neck of baby; can get tighter as baby comes down; compressing cord which can compress vein and cut off O2 supply to baby.

Cord: 2 arteries and 1 vein; oxygen is in vein (veins do not have muscular walls)

130
Q

growth hormones - fetal - post-publital

A

fetal: insulin most powerful growth hormone

pre-pubital: growth hormone

post-pubital: estrogen and testosterone

131
Q

erb’s palsy

A

injury to newborn as a result of birth; stretch injury to brachial plexus causing paralysis of muscled, inward turn, and hand faced palm up in back

  • will recover quickly

Neonate (2 decks)

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