Fetal and Neonatal Medicine Flashcards
What to take into consideration for maternal hx
GBS status Mom's age, ethnicity, SES PMHx, social hx, exposures Prior pregnancies and outcomes Present pregnancy Labor and delivery Half of perinatal mortality and morbidity results from pregnancies identified before delivery as high-risk
Pregnancy complications
Maternal HTN, DM, idiopathic thrombocytopenic purpura (ITP), hyperthyroid?
Anemia and hypoxia are concerns with placental problems
Multiple gestations?
Problems with amount of amniotic fluid volume?
-Oligohydramnios is worse than polyhydramnios
–4x more common
–Can cause faulty lung development
How was baby delivered? Why?
-If C-section, how long did labor last beforehand?
Any issues at time of delivery?
-CP?
-Meconium?
–Below cords can cause inhalation pneumonia
-Shoulder dystocia?
–Brachial plexus or clavicle injury
How can maternal DM affect the newborn?
Risk of limb deformities, congenital heart dz, large for gestational age, hypoglycemia, shoulder dystocia
DM type I is high risk- must be in fantastic control before pregnancy
How can maternal heart dz or HTN affect the newborn?
Risk of IUGR
How can maternal drug addiction affect the newborn?
Neonatal abstinence syndrome
This problem is made worse by the criminalization of pregnancy and drug use: mothers avoid prenatal care
Jaundice and causes
Indicates too much bilirubin in the blood Physiologic Breast milk Rh incompatibility Gilbert syndrome Criggler-Naijar syndrome Rotor syndrome Dubin Johnson syndrome
Physiologic jaundice
Liver is immature
Starts 24 hrs after birth, gets worse thru days 3 or 4, then gets better
Rise per day is <5 mg/dL, peak never exceeds 15 mg/dL
Happens bc their bodies are inefficient in clearing bilirubin
Breast milk jaundice
Pregnanediol in milk interferes with conjugation of bilirubin
Bili level may get as high as 20 mg/dL
Tx: may need phototherapy, if level reaches 20 may suspend breastfeeding x 24 hrs
Rh incompatibility- jaundice
Jaundice starts earlier and is worse
Caused by either isoimmunization or A-B-O incompatibility
A-B-O incompatibility happens when…
The mother is type O and the baby is B, A, or AB
The mother is type A and their baby is B or AB
The mother is type B and the baby is A or AB
Causes of jaundice when it appears at birth or within first 24 hrs of life
Rh incompatibility
Sepsis
Causes of jaundice when it appears on 2nd and 3rd day of life
Physiologic jaundice
Breast milk jaundice
Criggler Naijar syndrome
Causes of jaundice when it appears on 3rd-7th day of life
Infective causes
Causes of jaundice when it appears after 7th day of life
Other syndromes
Sx of jaundice in newborns
Yellow skin/sclera Sleepiness Poor feeding Dark urine May progress (untreated) to fever, vomiting, and high-pitched cry (kernicterus)
Yellow skin/sclera in jaundice
Bili >5 mg/dL = jaundice in babies (>2 in adults)
As level increases, you see jaundice more distally
5 mg/dL = head and neck
10 mg/dL = trunk and arms
15 mg/dL = legs as well
20 mg/dL = palms and soles
Kernicterus
Bilirubin encephalopathy caused by bilirubin’s toxicity to the basal ganglion. Bilirubin is lipid soluble and can cross the blood brain barrier.
Phase 1 of kernicterus
Hypotonia
Poor suck response
Lethargy
Altered sensorium
Phase 2 of kernicterus
Fever
Hypertonia going to opisthotunus (bent backwards)
Phase 3 of kernicterus
High-pitched cry
Seizures
Death
Consequences of kernicterus
Long-term survivors severely impaired
- CP
- UPward gaze palsy
- Sensorineural hearing loss
When is kernicterus more likely to occur?
Babies born with asphyxia, prematurity, or sepsis
Tx for jaundice
Increase PO intake
- >10 needs supplementation
Phototherapy
-Eyes need protection against retinal damage
Babies with kernicterus may need exchange transfusions and tx with barbiturates that enhance conjugation of the bili
Things that affect evaluation of the neonate
Full term or preterm?\
Average for gestational age? Small for gestational age? Large for gestational age?
APGAR score at birth?
How to determine gestational age by exam
What is the baby’s resting posture? Flexion? Partial flexion? Extension?
Perform square window, arm recoil, popliteal angle, scarf sign, ad heel to ear
Examine skin for lanugo and vernix
-Micropreemies don’t have lanugo
Examine the palmar and sole creases
-Full term has creases on foot
Palpate the breast tissue: flat? Breast bud?
Examine the ear: how well-formed is the cartilage
-Preemie ears don’t bounce back
Genital exam. Boy: rugae? Means closer to term. Are the testes descended? Girl: do the labia cover the clitoris?
Risks of prematurity
Respiratory distress
Risks of IUGR
Increased risk of mortality, possibly acidotic from birth asphyxia, possible hypotension and/or hypoglycemia
Causes of symmetrical IUGR
TORCH infections
Causes of asymmetrical IUGR
Poor placental perfusion due to smoking or maternal HTN
Common morbidities associated with prematurity
Congenital anomalies Infection Intraventricular hemorrhage -Dx by u/s Necrotizing enterocolitis -Dx by hemoccult Respiratory distress syndrome -Ground glass appearance on CXR; tx with surfactant Chronic lung dz when older
When is there increased risk for chronic lung dz when older in preemies?
RSV
More frequent infections
Asthma
Bronchopulmonary dysplasia (mimics asthma but seen in preemies treated for resp. distress)
Morbidities in full term infant
Complications of birth asphyxia: brain damage, CP, seizures, profound hypoglycemia
Birth trauma: fxs, palsies
- Clavicle or humerus MC
-Brachial plexus injuries not uncommon after difficult births of large babies
Congenital anomalies: palate, GI or GU tract
Congenital heart defects: MC VSD, most common CYANOTIC defect Tetralogy of Fallot
What are the palate, GI, or GU tract anomalies?
Cleft lip and/or palate
Esophageal atresia, pyloric stenosis, malrotation (volvulus), omphalocele, gastroschisis
Epispadias or hypospadias, ambiguous genitalia, bladder exstrophy
