Extra Neonatology Flashcards
A newborn infant was admitted in the NICU due to difficult delivery with *1/1 an AS of 3,4,5,7. 2 hours post partum you noted patient to be hypotonic,
on flexion position, with hyperactive tendon reflexes and lethargic. What
is the stage of the infant’s HIE
Stage 2
A newborn infant with a low AS required PPV and subsequent intubation. *0/1 However he remains unresponsive to resuscitation effort and you noted a asymmetric breath sound, you are considering a pneumothorax. You will perform a needling in this patient and you had a gauge 23 butterfly
needle on hand, you will puncture what intercostal space
4th ics
A newborn infant was delivered via CS. At 30th MOL, patient was noted *0/1 with tachypnea and expiratory grunting. You requested a CXR with result
of prominent pulmonary vascular markings, fluid in the intralobar fissures, overaeration, flat diaphragms. What is your primary diagnosis?
Transient tachypnea of the newborn
A premature baby was born with multiple craniofacial abnormalities, *0/1 withdrawal symptoms and hypertonia. Which agent is responsible for this signs and symptoms?
Toluene
Which is the most serious complication of chronic oligohydramnios? *
Pulmonary hypoplasia
WHich of the following has small anterior and posterior fontanels?
a. Congenital rubella syndrome
b. Congenital toxoplasmosis
c. Osteogenesis imperfecta
d. Intrauterine growth restriction
B. Congenital toxoplasmosis
A neonate was brought to your clinic for well-baby consult. The mother complained that he has excessive tearing of the right eye. What is your
plan of action?
a. Cold compress
b. Prescribed an oral antibiotic
c. Do crigler massage
d. Prescribed a topical antibiotic
C. Do criggler massage
Retinopathy of prematurity has been specifically identified to result from which of the following factors?
a. Prematurity
b. Oxygen administration
c. Low birth weight <1200grams
d. Vascular endothelial growth factor
D. Vascular endothelial growth factor
Which of the following is incorrectly paired? *
a. Micropreemie <800grams
b. ELBW <1000grams
c. VLBW <2000grams
d. LBW <2500 grams
c. VLBW <2000grams
It should be <1500 grams
A mother was diagnosed to have gestational diabetes at 8th month of gestation. She did not have any medications nor did she modify her diet.
The likely outcome of the baby she is carrying will be:
a. The baby may likely have major congenital malformations
b. The baby may likely to have minor malformations
c. The baby may likely to have physiologic abnormalities
d. The baby will be normal
c. The baby may likely to have physiologic abnormalities
A 4 day old newborn was noted to be jaundice from head down to the chest. Mother complained that she do not have enough milk and her baby is always hungry. Mother blood type is B as well as infant’s blood type.
What is your plan of action?
a. Shift to formula feeding
b. Advised to continue breastfeeding
c. Start an IV antibiotic
d. Patient is for exchange transfusion
b. Advised to continue breastfeeding
A mother was found to be reactive for HBsAg. At birth, which of the following should be done?
a. Give Hepa B vaccine only
b. Give Hepa Ig only
c. Request for a confirmatory test for the baby d. Mother may breastfeed her baby
d. Mother may breastfeed her baby
In the NRP guide to determine need for resuscitation, the following are the questions to ask except?
a. Is the amniotic clear?
b. Is the baby breathing or crying?
c. Good muscle tone?
d. Cyanotic or acrocyanotic?
d. Cyanotic or acrocyanotic?
(Bwiset tricky ACRO :()
A term well infant was born via NSD. No complication was noted during delivery and baby was roomed in with mother. At 2nd DOL, the infant was noted with bloody meconium but still with good suck, cry, activity and was sleeping like a well-baby. Which test will you request to confirm your diagnosis?
a. Barium enema
b. Gastric lavage with normal saline
c. PFA
d. Apt test
d. Apt test
What is the most important & effective action in neonatal resuscitation?
a. Perform chest compression to improve circulation
b. Ventilate the baby’s lungs to prevent respiratory failure
c. Administer fluids for adequate volume replacement
d. Administer epinephrine to prevent cardiac failure
b. Ventilate the baby’s lungs to prevent respiratory failure
What is the recommended radiation Exposure in pregnancy?
<5 rad
Xrays: <0.1 rad
CT scan: 5 rad
** before pregnancy (or 0-2wks aog) exposure of 5-10 rad may lead to miscarriage
2-8wks aog, exposure to >25 rad may lead to congenital abnormalities and IUGR
>= 25 rad by 25 weeks aog or more may lead to intellectual disabilities
MRI and UTZ is safe, no radiation
What are the intrauterine diagnostics of fetal disease
- amniocentesis
- Chorionic villi sampling
- Cordocentesis or peri umbilical blood sampling (PUBS)
- Aneuploidy screening
What are the four international fetal medicine and surgery society consensus statement on fetal surgery?
- Fetal surgery candidate should be a SINGLETON with no other abnormalities observed on level II ultrasound, karyotype or alpha-fetoprotein level or viral cultures
- The DISEASE process must NOT be SO SEVERE that the fetus cannot be saved and also NOT SO MILD that the infant do well with postnatal therapy
- The family must be fully counseled and understand the risks and benefits of fetal surgery and they must agree the long-term follow up the track efficacy of the fetal intervention
- A multidisciplinary team must concur that the disease process is fatal without intervention, that the family understands the risk and benefits, and that the fetal intervention is appropriate
What are the four groups or categories of High risk infants?
- Preterm infants
- Infants with special needs or dependence on technology
- Infants at risk due to family issues
- Infants with anticipated early death
Definition of age of prematurity according to WHO
- Extremely preterm : less than 28 weeks
- Very preterm: 28–31 6/7 weeks
- Moderate to late preterm: 32- 36 6/7 weeks
Common life-threatening congenital anomalies:
Presents with respiratory distress in the delivery room nasogastric tube cannot be passed through nares
CHOanal ATRESIa
Suspect CHARGE (coloboma of eye, choanal atresia, retardation genital and ear anomalies) syndrome
Common life-threatening congenital anomalies
Micrognathia cleft palate airway obstruction
Pierre – Robin syndrome
Scaphoid abdomen, Bowel sounds present in chest, respiratory distress
Diaphragmatic hernia
Polyhydramnios, aspiration pneumonia, excessive salivation, nasogastric tube cannot be placed in stomach
Tracheoesophageal fistula
Also suspect VATER (Vertebral defects, Important for a nose, tracheoesophageal fistula, radial and renal dysplasia)syndrome
Polyhydramnios, bile- stained emesis, abdominal distention, suspect trisomy 21, cystic fibrosis, or cocaine use
Intestinal obstruction, volvulusm duodenal atresia, ileal atresia
Polyhydramnios, intestinal obstruction
Gastroschisis, omphalocoele
Oligohydramnios, anuria, pulmonary hypoplasia, pneumothorax
POTter Syndrome, renal agenesis
Polyhydramnios elevated alpha fetoprotein, decreased fetal Activity
Neural tube defects, anencephaly, meningomyelocele
Cyanosis, hypertension, and murmur upon delivery
Ductus dependent congenital heart disease
Grading of intraventricular hemorrhage based on utz
grade I: bleeding is confined to the germinal matrix–subependymal region or to <10% of the ventricle (approximately 35% of IVH cases);
grade II: intraventricular bleeding with 10–50% filling of the ventricle (40% of IVH cases);
grade III: >50% of the ventricle is involved, with dilated ventricles
Prevention of Intraventricular Hemorrhage and Periventricular Leukomalacia
- Single dose of antenatal Corticosteroids at 24-37 weeks AOG
- Prophylactic low-dose indomethacin (0.1 mg/ kilogram per day) x 3 days on VLBW —> reduces incidence of IVH
Treatment/management for intraventricular hemorrhage
- supportive (anti convulsants, treat anemia, hypoxia and coagulopathies (ffp transfusion, etc)
- treat shock and acidosis, proper fluid resuscitation
- VP shunt for progressive and symptomatic PPH (post Hemorrhagic hydrocephalus)
- ventriculosubgaleal shunt
What are the poor predictive values for death or disability after hypoxic ischemic encephalopathy? (9)
- Low 10 minute Apgar score (0-3)
- Need for CPR in the delivery room
- Delayed onset of spontaneous breathing (more than 20 minutes)
- Severe neurologic signs like, hypotonia or hypertonia
- Seizures on sat in less than 12 hours or difficult to treat seizures
- Severe prolonged more than (~7days) EEG findings including burst suppression pattern
Diagnostics of HIE
MRI - most sensitive, on 1st 3-5 days from event
UTZ - limited utility of evaluation but initially preferred modality in evaluation of preterm infant
Amplitude integrated EEG (aEEG) - help determine highest risk for devt sequelae of neonatal brain injury
EEG with concurrent video for seizure monitoring
Treatment of HIE
THERAPEUTIC HYPOTHERMIA
- done w/in 1st 6 hrs after birth, maintain core rectal/esophageal temp of 33.5 c x 72hrs
- erythropoietin : ongoing studies, promising outcomes
For seizures
Phenobarbital - 1st line
Phenytoin/Levetiracetam - 2nd line
Midazolam, topiramate, lidocane - 3rd line
SUpportive treatment
Diagnosis of BRAIN DEATH after HIE
- coma unresponsive to pain,auditory or visual stimulation
-PCO2 of 40-60 w/0 vent support - absence of brain stem reflexes
These must occur in the absence of hypothermia, hypotension, or depressant drugs
It is the injury of C5 and C6. Infant loses the power to abduct the arm from the shoulde r, rotate the arm externally, and supinate the forearm. The characteristic position consists of adduction and internal rotation of the arm with pronation of the forearm. Power to extend the forearm is retained, but the biceps reflex is absent; the Moro reflex is absent on the affected side. The outer aspect of the arm may have some sensory impairment. Power in the forearm and hand grasps is preserved unless the lower part of the plexus is also injured; the presence of hand grasp is a favorable prognostic sign.
Erb’s Palsy
a rare form of brachial palsy in which injury to the 7th and 8th cervical nerves and the 1st thoracic nerve produces a paralyzed hand and ipsilateral ptosis and miosis (Horner syndrome) if the sympathetic fibers of the 1st thoracic root are also injured. Mild cases may not be detected immediately after birth
May result to shoulder drop
Klumpke paralysis
Treatment/management for brachial plexus injuries
Initial conservative management with monthly ff up
-operation by 3 months if no functional improvement ( neuroplasty, neyrolysis, end-to-end anastomosis, nerve grafting)
- partial immobilization and appropriate positioning (brace or splint on the 1st 1-2 weeks.
- paralysis of upper arm has better prognosis than paralysis of lower part
-if paralyzed gentle massage and ROM excewrcises by 7-10 days old.
Patient delivered with difficulty via NSD at a lying in clinic with BW 4300g, AS 4,6. noted cyanosis and irregular labored breathing despite resuscitation efforts. Abdomen doesnt bulge with inspiration, decreased breath sounds on the right. Diaphragm thrust not appreciated on the right side. What is the impression?
PHRENIC NERVE INJURY
C3-C5 involvement
Diagnosis established by UTZ or fluroscopic examination which reveals elevation of affected diaphragm and see saw movements during respiration.
Tx/Mgt:
O2 support, cpap, supportive managament
Pulmo infections seriouscomplication
May resolve Spontaneously in one to two months
Surgical plication of the diaphragm may be indicated
Upon delivery, newborn is noted limp with no respirations, Heart rate 80. What is the first step to do?
Stimulate patient, dry, suction secretions
Turn baby delivered via cesarean section. After 60 seconds stimulation, baby has no respirations and heart rate 80. What should be done?
Positive pressure ventilation
Endotracheal tube sizes based on Weight
<1000g : 2.5
1000-2000g: 3
2000g above: 3.5
Corrective steps to improve PPV ventilation
MRSOPA
Mask readjustment
Reposition Head
Suction mouth and nose
Open mouth
Pressure increase
Alternate airway
How do you give intra endotracheal epinephrine if there is no IV access yet during neonatal resuscitation?
Epinephrine 1:10 000 solution at 0.5-1 ml/kg intratracheally
WHEN it is REASONABLE to STOP neonatal resuscitation despite all interventions (ivf, epinephrine, intubation, proper CPR) ?
After 10 (TEN) MINUTES of adequate CPR
True or false:
Meconium stained non vigorous child requires tracheal intubation to attempt suctioning meconium below the cords
FALSE
No, NRP 7th edition no longer support this practice
Follow same initial steps of resuscitation
On congenital scan, patient is diagnosed with cervical teratoma And critical high airway obstruction syndrome. With pre-natal Multi specialty planning, what is the possible surgical option for the patient to secure the airway upon delivery?
EXIT (ex utero intrapartum treatment)
Procedure that allows time to secure the patient’s airway before the baby is separated from the placenta. Uteroplacental gas exchange is maintained during this procedure
Location of angiocatheter insertion in cases of
A. Neonatal Pneumothorax
B. Neonatal pleural effusion
A. 2nd ICS midclavicular line
B. 4th or 5th ICS anterior axillary line
Potential causes of neonatal apnea and bradycardia
Until when is the Apnea of prematurity
(No direct answer from nelson)
“ incidence rapidly decreases to 20% of premies <34 wks AOG
AAP: resolves in 36-37wks PCA in neonates born >28wks AOG, may proceed beyond term in those born <28wks AOG
What is the etiology of respiratory distress syndrome
SURFACTANT DEFICENCY
- In the absence of pulmonary surfactant, significantly increased alveolar tension leads to atelectasis, and the ability to attain an Adequate FRC is impaired. This leads to progressive injury to epithelial and endothelial cells of the lungs forming hyaline membrane which further impairs oxygenation
Preventive measures for respiratory distress syndrome
- Elective deliveries at 39 weeks AOG
- Administration of corticosteroids before 37 weeks AOG on high-risk pregnancies
Treatment of respiratory distress syndrome
- Supportive management
-NCPAP. Maintain PaO2 at 50 to 70 MM Hg (91-95% o2sat) To prevent oxygen toxicity - INSURE (intubate, surfactant and extubate)
- MIST (Minimally invasive surfactant therapy)
- LISA (Less invasive surfactant administration)
- Empiric antibiotic therapy until blood cultures are available
Mode of mechanical ventilation where in achieve desired alveolar ventilation by using smaller title volumes and higher rates ( 300-1200 breaths/min)
High frequency ventilation
What is the approach of choice for the delivery room management of a preterm neonate at risk for RDS
Prophylactic NCPAP
When is synthetic surfactant warranted in RDS?
neonate with RDS who fail NCPAP Who require intubation and mechanical ventilation
Most common type of diaphragmatic hernia about 90% of neonatal cases
Bochdalek (posterolateral diaphragm)
Initial management strategies for diaphragmatic hernia
- prenatal counselling and planning (if detected in utero)
-delivery at a multi disciplinary tertiary hospital - AVOID PROLONGED MASK VENTILATION. Intubate right away if in respi distress to prevent bowel air dilatation (mech vent, HFOV or ECMO)
- insert OGT immediately for bowel decompression
-Gentle ventilation with permissive hypercapnia (PCO2 50-70%) reduces mortality - OPERATION (silicone patch, native tissue repair)
Initial treatment for meconium plug
Glycerin suppository
Rectal irrigation with isotonic saline
Gastrografin enema(diagnostic and therapeutic
Greatest risk factor for necrotizing enterocolitis
PREMATURITY
Three major risk factors of necrotizing enterocolitis
- Prematurity
- Bacterial colonization of the gut
- Formula feeding
What is the most effective strategy on preventing necrotizing enterocolitis
USE OF HUMAN MILK
When is surgery advised in umbilical hernia?
If the hernia PERSIST after 4 to 5 years old
CAUSES symptoms, become strangulated
Progressively enlarges after 1 to 2 years
Give examples of omophalomesenteric duct (OMD) remnants
Meckel’s diverticulum
Umbilical polyp
Patent urachus
