exam 1 - neonatal Flashcards
fetus and newborn
-Late fetal-early neonatal period has highest mortality rate of any age interval
-Perinatal mortality: Deaths occurring from 20 week of gestation until 28th day after birth
-Neonatal mortality: Deaths occurring from birth to 28th day of life
-Infant mortality rate: Deaths occurring during neonatal and post-neonatal periods
-Low birthweight (LBW): Infants having birthweights of < 2,500 grams -> 40x greater risk of mortality
-Very low birthweight (VLBW): Infants weighing < 1,500 gram -> 200x greater risk of mortality
maternal risk factors
-Previous LBW birth
-Low socioeconomic status
-Low level of education
-Poor antenatal care
-Maternal age < 16 or > 35 years
-Short interval periods between pregnancies
-Cigarette smoking, alcohol, and illicit drug use
-Physical or psychologic stresses
-Single parent
-Low pre-pregnancy weight (< 45 kg)
-Poor weight gain during pregnancy (< 10 lbs)
-Black race (2 x risk)
fetal to neonatal physiology transition
-clamping of umbilical cord:
-Eliminates low pressure system of the placenta and increases systemic BP
-Decreased venous return from placenta decreases right atrial pressure
-breathing begins:
-Air replaces lung fluid
-Pulmonary resistance decreases, increases blood flow to lungs, increases pulmonary venous return to LA – LA pressure > RA pressure = !closure of foramen ovale! :)
-Arterial oxygen tension increases = !ductus arteriosus begins to constrict!
routine delivery room care: Apgar score
-Performed at 1 and 5 mins after birth
-Normal: 8-9 at 1 and 5 minutes
-Close attention: 4-7
-Cardiopulmonary arrest, bradycardia, hypoventilation, or CNS depression: 0-3
-Most with low Apgar scores improve with assisted ventilation via face mask or by ET intubation
routine delivery room care
-Erythromycin (topical) for neonatal gonococcal and chlamydial conjunctivitis prophylaxis
-Antiseptic skin/cord care to prevent spread of pathologic bacteria from one infant to another and to prevent disease in individual infant
-Antibiotic ointment, topical alcohol, or chlorhexidine (defense against gram-positive organisms, like S. aureus)
-Vitamin K prophylaxis (IM) to prevent hemorrhagic disease of the newborn
-Hepatitis B vaccine prior to discharge
-Warmth
-Ideal temperature is neutral thermal environment
-Heat production is via non-shivering thermogenesis due to -> Brown fat: Highly vascular, many mitochondria, surrounds large blood vessels
delivery room resuscitation
-Cyanosis
-Acrocyanosis (hands and feet) is common and usually normal- every a few days after
-Central cyanosis (trunk, mucosal membranes, and tongue) -> any time after birth and is always from serious underlying condition (below)
-Life-Threatening Congenital Malformations
-Choanal atresia and other lesions obstructing the airway
-Intrathoracic lesions: Cysts, diaphragmatic hernias
-Malformations that obstruct the GI tract at level of esophagus, duodenum, or colon
-Gastroschisis (intestinal necrosis), omphalocele
delivery room resuscitation: asphyxia
-Asphyxia w/ severe bradycardia or cardiac insufficiency reduces or stops tissue blood flow -> ischemia
-With severe or prolonged intrauterine/neonatal asphyxia, vital organs affected
-Maternal risk factors: Ds that interfere with uteroplacental perfusion, epidural anesthesia, vena caval compression syndrome, medications
-Fetal/newborn risk factors:
-Immature infants (< 1000 g) – Surfactant deficiency
-Newborns (premature): Respond paradoxically to hypoxia with apnea NOT tachypnea!
-#1 cause of MI in neonates is respiratory related not cardiac
-Episodes of intrauterine asphyxia may depress neonatal CNS –> may not initiate ventilatory response at birth and may undergo another episode of asphyxia
delivery room resuscitation: shock
-Pallor, poor cap refill time, lack of palpable pulses, hypotonia, cyanosis, and eventually cardiopulmonary arrest
-MC cause is blood loss before or during labor (hypovolemia)
-Severe intrauterine bacterial sepsis (distributive)– mottled, hypotonic, and cyanotic with diminished peripheral pulses
-Peripheral, symmetric gangrene (purpuric rash) - often sign of hypotensive shock with severe congenital bacterial infections
-Tx:
-Airway stabilization and ventilatory support
-Hypovolemic shock: Repeat boluses of 10-15 cc/kg of normal saline or LR (little bit less than normal hypovolemic shock- dont need to know)
-Anemia: Blood transfusion
-Dopamine, epinephrine, cortisol, as needed
birth injuries (test)
Caput Succedaneum:
-Diffuse, edematous, dark swelling of soft tissue of scalp that extends across midline and suture lines
-Often following prolonged labor
-boggy
-over the periosteum -> free flowing
Cephalohematoma:
-Subperiosteal hemorrhage that doesnt cross suture lines surrounding respective bones
-May organize, calcify, and form a central depression
-tx-
-observe- they will absorb
birth injuries: facial nerve injury
-Asymmetric, crying face
-Eye does not close, nasolabial fold absent, side of mouth droops at rest
birth injuries: brachial plexus injury (test)
Phrenic nerve palsy: C3-5
– May lead to diaphragmatic paralysis/respiratory distress
Erb-Duchenne paralysis: C5-6 injury
– Cannot abduct arm at shoulder, externally rotate arm, or supinate forearm
Klumpke paralysis: C7-C8, T1
– Paralyzed hand with ipsilateral Horner syndrome, claw hand
-Tx: Supportive, active/passive ROM exercises, nerve grafting
birth injuries: spine/spinal cord injuries
-If excessive force during vertex/breech delivery
-Rotational – C3-4
-Longitudinal – C7-T1
-Spinal cord: Flaccid, apneic, and asphyxiated on PE
birth injuries: clavicle fractures
-usually macrosomic infants (big) after shoulder dystocia
-Asymmetric Moro reflex- briskly drop pt -> if clavicle fractured -> the arm wont go up on that side
-MC birth trauma fracture
-Tx: Immobilization
birth injuries: visceral trauma
-Macrosomic, extremely premature infants
-Liver rupture: Anemia, hypovolemia, shock, hemoperitoneum, and DIC
-Adrenal rupture: Flank mass, jaundice, hematuria
newborn hernias
gastroschisis:
-Herniation of bowel through abdominal wall 2-3 cm lateral to the umbilicus
-there is no sac to protect this -> risk of infection and dehydration
-more risk
-Umbilical cord should be inspected –> confirm 2 arteries, 1 vein, and absence of herniation of abdominal contents –> !omphalocele!:
-Bleeding from cord suggests coagulation disorder, chronic discharge may be a granuloma
omphalitis:
-Erythema around umbilicus
- may cause portal vein thrombophlebitis and subsequent extrahepatic portal HTN)
-know the picture and difference
PE of newborn: genitalia
-Testes should be descended at term -> Occasionally in inguinal canal (cryptorchidism -> testicular ca risk)
-Scrotal swelling: Hernia, transient hydrocele, in utero torsion of testes
-Urethra inspection to r/o epispadias/hypospadias
-Female genitalia: May have milky white/blood-streaked vaginal discharge (from maternal hormone withdrawal)
-Imperforate hymen may cause discharge buildup -> lower midline abdominal mass from enlarged uterus
-Clitoral enlargement with fusion of labia majora -> suggests adrenogenital syndrome or exposure to masculinizing maternal hormones
respiratory distress syndrome (hyaline membrane disease)
-Occurs after onset of breathing and is assoc with insufficiency of pulmonary surfactant
-Surfactant prevents atelectasis by reducing surface tension at low lung volumes when it is concentrated at end expiration as alveolar radius decreases
-Surfactant contributes to lung recoil
-Without surfactant -> surface tensions are not reduced -> atelectasis during end expiration
-ALWAYS THINK THIS FIRST WHEN THERE IS RESPIRATORY DISTRESS
-Risk Factors: Prematurity, low gestational age, delivery of prior preterm infant with RDS, maternal diabetes, hypothermia, fetal distress, asphyxia, males, second-born of twins, and delivery by C-section
respiratory distress syndrome (Hyaline Membrane disease): clinical manifestation
-Initially: Cyanosis, tachypnea, nasal flaring, intercostal/sternal retractions, and GRUNTING (BAD); over 72 hours - increased distress, hypoxemia
-CXR findings: Ground-glass haze surrounding air-filled bronchi or white-out (severe)
-Uncomplicated cases show spontaneous improvement – diuresis and marked improvement of edema
-Severe cases (edema, apnea, respiratory failure) – assisted ventilation
respiratory distress syndrome (Hyaline Membrane disease): complications: PDA
-Patent Ductus Arteriosus
-bc poor oxygenation -> oxygen normally stimulates the closure of PDA
-Less responsive to vasoconstrictive stimuli, complicated by hypoxemia during RDS -> resulting shunt between pulmonary and systemic circulation -> right sided HF, pulmonary edema
-L->R -> increase PVR -> reverses to R ->L -> when you treat you start to overload the pt -> HF
-Widened pulse pressure, peripheral pulses palpable/bounding
-Continuous murmur (systole/diastole)
-HF and pulmonary edema resulting in rales and hepatomegaly
-CXR with cardiomegaly and pulmonary edema; echocardiogram with ductal patency, Doppler with left-to-right flow (back to PA/lungs)
-Treatment
-With RDS: Fluid restriction, diuretic administration; after 1-2 days no improvement –> prostaglandin synthetase inhibitor, ibuprofen, !indomethacin!, or acetaminophen
-Surgical ligation/catheter-based occlusion may be required
respiratory distress syndrome (Hyaline Membrane disease): complications: pulmonary air leaks
-Assisted ventilation may cause overdistention of alveoli > rupture > interstitial emphysema > PTX/pneumomediastinum
-Confirmed by CXR
-Treatment: Symptomatic PTX > pleural chest tube
respiratory distress syndrome (Hyaline Membrane disease): complications: bronchopulmonary dysplasia (chronic lung ds)
-Typically develops following ventilation for RDS complicated by PDA and/or pulmonary air leaks
-Failure of RDS to improve > 2 weeks, need for prolonged ventilation, and oxygen therapy required at 36 weeks of post-conceptual age (development of superoxides, hydrogen peroxide, and free radicals > disrupt membrane) are characteristic
-Clinical Manifestations
-Oxygen dependence, hypercapnia with compensatory metabolic alkalosis, pulmonary HTN, poor growth, development of R-sided HF
-CXR: Lung opacification > cyst development = Sponge-like appearance
-Treatment
-May need mechanical ventilation for several months
-Tracheotomy may be indicated (prevent subglottic stenosis)
-Dexamethasone may reduce inflammation, improve pulmonary function, enhance weaning of pts from ventilation
respiratory distress syndrome (Hyaline Membrane disease): complications: retinopathy of prematurity (retrolental fibroplasia)
-Leading cause of blindness in VLBW infants (< 1500 grams)
-Caused by acute and chronic effects of oxygen toxicity on developing blood vessels of the premature infant’s retina
-Excessive arterial oxygen tensions > vasoconstriction immature retinal vasculature > vaso-obliteration if prolonged
-Subsequent proliferative phase – Extraretinal fibrovascular proliferation > fibrous proliferation behind lens produces leukocoria/displacement of lens > causes glaucoma
-Treatment: Spontaneous resolution versus laser therapy
meconium aspiration syndrome
-Presence of meconium-stained amniotic fluid suggests in utero distress with asphyxia, hypoxia, and acidosis
-Aspiration may occur in utero or -> MC -> immediately after delivery
-Meconium aspiration PNA
-Clinical Manifestations: Tachypnea, hypoxia, hypercapnia, atelectasis, small airway obstruction > air trapping, overdistention, and extra-alveolar leaks
-1-2 days: Chemical pneumonitis
-CXR: Patchy infiltrates, hyperinflation, high incidence of air leaks
-Treatment: Supportive care, ventilation; surfactant therapy, inhaled nitric oxide, ECMO
persistent pulmonary HTN of the newborn
-Severe hypoxemia w/o evidence of parenchymal lung or structural heart disease
-Often with asphyxia or meconium-stained fluid
-R to L shunting through a patent FO, PDA, and intrapulmonary channels
-Dx: Confirmed via echo –> elevated pulmonary artery pressures and sites of R to L shunting
-Tx:
-Supportive care, assisted ventilation; inhaled nitric oxide, pulmonary artery vasodilating agent; ECMO
