Fetal Medicine Flashcards
Describe Apgar score parameters?
A score of 0-3 is very low score, between 4-6 is moderate low and between 7 - 10 means the baby is in a good state
Apgar score components include?
Pulse Respiratory effort Colour Muscle tone Reflex irritability
A score of 0 in the agpar score parameters is?
Absent pulse No resp effort Blue all over Flaccid No reflex irritability
A score of 1 in the agpar score parameters is?
< 100 pulse
Resp effort weak & irregular
Body pink, extremities blue
Limb flexion Grimace
A score of 2 in the agpar score parameters is?
> 100 pulse resp effort Strong, crying Pink baby Muscle tone - Active movement Cries on stimulation/sneezes, coughs
Normal term babies often have hypoglycaemia especially in the first 24 hrs of life
true
Normal term babies often have hypoglycaemia without sequalae due to
they can utilise alternate fuels like ketones and lactate
There is no agreed definition of neonatal hypoglycaemia but a figure of < 2.6 mmol/L is used in many guidelines.
true
Transient hypoglycaemia in the first hours after birth is common.
true
Persistent/severe hypoglycaemia may be caused by:
preterm birth (< 37 weeks) maternal diabetes mellitus IUGR hypothermia neonatal sepsis inborn errors of metabolism nesidioblastosis Beckwith-Wiedemann syndrome
Neonatal hypoglycaemia leads to hypo/hyperthermia
hypothermia
Neonatal hypoglycaemia symptoms - autonomic (hypoglycaemia → changes in neural sympathetic discharge)
‘jitteriness’
irritable
tachypnoea
pallor
Neonatal hypoglycaemia symptoms - neuroglycopenic
poor feeding/sucking weak cry drowsy hypotonia seizures
Management of neonatal hypoglycaemia depends on
severity of the hypoglycaemia and if the newborn is symptomatic
Management of neonatal hypoglycaemia - asymptomatic
encourage normal feeding (breast or bottle)
monitor blood glucose
Management of neonatal hypoglycaemia - symptomatic or very low blood glucose
admit to the neonatal unit
intravenous infusion of 10% dextrose
Causes of neonatal hypotonia include:
neonatal sepsis
Werdnig-Hoffman disease (spinal muscular atrophy type 1)
hypothyroidism
Prader-Willi
Causes of maternal hypotonia include:
maternal drugs e.g. benzodiazepines
maternal myasthenia gravis
Neonatal sepsis occurs when a serious bacterial or viral infection in the blood affects babies within the first ? days of life.
28
Neonatal sepsis is categorised into early-onset and late-onset
- define
(EOS, within 72 hours of birth)
LOS, between 7-28 days of life
Neonatal sepsis account for 10% of all neonatal mortality
true
Black race is an independent risk factor for group B streptococcus-related sepsis
true
The overall most common causes of neonatal sepsis are ?, accounting for approximately two thirds of neonatal sepsis cases
The overall most common causes of neonatal sepsis are group B streptococcus (GBS) and Escherichia coli, accounting for approximately two thirds of neonatal sepsis cases
Early-onset sepsis in the UK is primarily caused by
Early-onset sepsis in the UK is primarily caused by GBS infection (75%)
Late-onset sepsis usually occurs via the transmission of pathogens from the environment post-delivery, this is normally from contacts such as the parents or healthcare workers
Infective causes are more commonly
coagulase-negative staphylococcal species such as Staphylococcus epidermidis, Gram-negative bacteria such as Pseudomonas aeruginosa, Klebsiella and Enterobacter, and fungal species
Risk factors of neonatal sepsis
Mother who has had a previous baby with GBS infection, who has current GBS colonisation from prenatal screening, current bacteruria, intrapartum temperature ≥38ºC, membrane rupture ≥18 hours, or current infection throughout pregnancy
premature
low birth weight
,aternal chorioamnionitis
Neonatal sepsis - Patients typically present with a subacute onset of what most commonly?
Respiratory distress (85%) Grunting Nasal flaring Use of accessory respiratory muscles Tachypnoea
Temperature is not usually a reliable sign as the temperature can vary from being raised, lowered or normal for neontal sepsis
Term infants are more likely to be ?
Pre-term infants are more likely to be ?
Term infants are more likely to be febrile
Pre-term infants are more likely to be hypothermic
Neonatal sepsis ix wht will usually establish the diagnosis
Blood culture
sepsis - in neonates, parameters on full blood examination are usually not always useful for diagnosis, rather may help to exclude healthy neonates
true
neonatal sepsis - what will sequential assessment will help to guide management and patient progress with treatment
crp
metabolic acidosis is particularly concerning for neonatal sepsis, particularly a base deficit of ≥10 mmol/L
true
first-line regimen for suspected or confirmed neonatal sepsis
intravenous benzylpenicillin with gentamicin
Neonatal Sepsis - Other important management factors to consider include
Maintaining adequate oxygenation status
Maintaining normal fluid and electrolyte status
Prevention and/or management of hypoglycaemia
Prevention and/or management of metabolic acidosis
Jaundice in the first 24 hrs is normal
false
always pathological
Causes of jaundice in the first 24 hrs
rhesus haemolytic disease
ABO haemolytic disease
hereditary spherocytosis
glucose-6-phosphodehydrogenase
Jaundice in the neonate from the c. 2-14 days is common (up to 40%) and usually physiological.
true
Jaundice in the neonate from the c. 2-14 days is common (up to 40%) and usually physiological. is most commonly seen in which babies
breastfed
If there are still signs of jaundice after 14 days a prolonged jaundice screen is performed, including:
conjugated and unconjugated bilirubin direct antiglobulin test (Coombs' test) TFTs FBC and blood film urine for MC&S and reducing sugars U&Es and LFTs
Causes of prolonged jaundice
biliary atresia hypothyroidism galactosaemia urinary tract infection breast milk jaundice congenital infections e.g. CMV, toxoplasmosis
Newborn resuscitation - first thing to do?
- Dry baby and maintain temperature
- Assess tone, respiratory rate, heart rate
- If gasping or not breathing give 5 inflation breaths
- Reassess (chest movements)
- If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1
Peripheral cyanosis, for example of the feet and hands, is very common in the first 24 hours of life and may occur when the child is crying or unwell from any cause
true
Central cyanosis can be recognised clinically when the concentration of reduced haemoglobin in the blood exceeds
5g/dl
the hyperoxia test / nitrogen washout test is used to
may be used to differentiate cardiac from non-cardiac causes
Describe The nitrogen washout test
The infant is given 100% oxygen for ten minutes after which arterial blood gases are taken. A pO2 of less than 15 kPa indicates cyanotic congenital heart disease
Causes of cyanotic congenital heart disease
tetralogy of Fallot (TOF)
transposition of the great arteries (TGA)
tricuspid atresia
Initial management of suspected cyanotic congenital heart disease
supportive care
prostaglandin E1
used to maintain a patent ductus arteriosus in ductal-dependent congenital heart defect
Acrocyanosis is
peripheral cyanosis around the mouth and the extremities
Acrocyanosis is always pathological
false
often seen in healthy newborns
It is caused by benign vasomotor changes that result in peripheral vasoconstriction and increased tissue oxygen extraction and is a benign condition
it occurs immediately after birth in healthy infants. It is a common finding and may persist for 24 to 48 hours.
Moro reflex is
Head extension causes abduction followed by adduction of the arms
Present from birth to around 3-4 months of age
Grasp reflex is
Flexion of fingers when object placed in palm
Present from birth to around 4-5 months of age
Rooting reflex is
Assists in breastfeeding
Present from birth to around 4 months of age
Stepping reflex is
Also known as walking reflex
Present from birth to around 2 months of age
Sudden infant death syndrome is the commonest cause of death in the first year of life. It is most common at
3 months of age.
Sudden infant death syndrome major risk factors
putting the baby to sleep prone parental smoking prematurity bed sharing hyperthermia/ head covering
Sudden infant death syndrome incidence increases in winter
true
Sudden infant death syndrome Protective factors
breastfeeding
room sharing (but not bed sharing, which is a significant risk factor)
the use of dummies (pacifiers)
Following a cot death siblings should be screened for
potential sepsis and inborn errors of metabolism.
The risk of SDLD decreases with gestation
true
50% of infants born at 26-28 weeks
25% of infants born at 30-31 weeks
risk factors for SDLD include
male sex
diabetic mothers
Caesarean section
second born of premature twins
SDLD Chest x-ray characteristically shows
‘ground-glass’ appearance with an indistinct heart border
SDLD mx
prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation
oxygen
assisted ventilation
exogenous surfactant given via endotracheal tube
Infantile colic describes a relatively common and benign set of symptoms seen in young infants. It typically occurs in infants aged?
less than 3 months old
Infantile colic sx
characterised by bouts of excessive crying and pulling-up of the legs, often worse in the evening.
Infantile colic occurs in up to 20% of infants. The cause of infantile colic is unknown.
true
Necrotising enterocolitis is one of the leading causes of death among premature infants.
true
Necrotising enterocolitis sx
feeding intolerance, abdominal distension and bloody stools, which can quickly progress to abdominal discolouration, perforation and peritonitis.
Abdominal x-rays are useful when diagnosing necrotising enterocolitis, as they can show:
dilated bowel loops (often asymmetrical in distribution)
bowel wall oedema
pneumatosis intestinalis (intramural gas)
portal venous gas
pneumoperitoneum resulting from perforation
air both inside and outside of the bowel wall (Rigler sign)
air outlining the falciform ligament (football sign)
Meconium aspiration syndrome refers to
respiratory distress in the newborn as a result of meconium in the trachea
Meconium aspiration syndrome occurs when?
in the immediate neonatal period
Meconium aspiration syndrome is more common in
post-term deliveries - babies born after 42 weeks
maternal hypertension, pre-eclampsia, chorioamnionitis, smoking or substance abuse.
commonest cause of respiratory distress in the newborn period.
Transient tachypnoea of the newborn
Transient tachypnoea of the newborn is caused by
delayed resorption of fluid in the lungs
Transient tachypnoea of the newborn is more common following?>
It is more common following Caesarean sections, possibly due to the lung fluid not being ‘squeezed out’ during the passage through the birth canal
Transient tachypnoea of the newborn CXR
Chest x-ray may show hyperinflation of the lungs and fluid in the horizontal fissure
Transient tachypnoea of the newborn mx
Supplementary oxygen may be required to maintain oxygen saturations. Transient tachypnoea of the newborn usually settles within 1-2 days
Microcephaly may be defined as
occipital-frontal circumference < 2nd centile
Microcephaly causes
normal variation e.g. small child with small head
familial e.g. parents with small head
congenital infection
perinatal brain injury e.g. hypoxic ischaemic encephalopathy
fetal alcohol syndrome
syndromes: Patau
craniosynostosis
Cleft lip and palate commonest variants are:
isolated cleft lip (15%)
isolated cleft palate (40%)
combined cleft lip and palate (45%)
Cleft lip and palate pathophysiology?
polygenic inheritance
maternal antiepileptic use increases risk
cleft lip results from failure of the fronto-nasal and maxillary processes to fuse
cleft palate results from failure of the palatine processes and the nasal septum to fuse
Cleft lip and palate problems?
feeding: orthodontic devices may be helpful
speech: with speech therapy 75% of children develop normal speech
increased risk of otitis media for cleft palate babies
Cleft lip and palate mx
cleft lip is repaired earlier than cleft palate, with practices varying from repair in the first week of life to three months
cleft palates are typically repaired between 6-12 months of age
on the Y chromosome there is a sex-determining gene (SRY gene) which causes differentiation of the gonad into a testis
true if absent (i.e. in a female) then the gonads differentiate to become ovaries
Ambiguous genitalia Most common cause in newborns is
congenital adrenal hyperplasia
Neonatal blood spot screening (previously called the Guthrie test or ‘heel-prick test’) is performed at?days of life
Neonatal blood spot screening (previously called the Guthrie test or ‘heel-prick test’) is performed at 5-9 days of life
Neonatal blood spot screening consists of?
congenital hypothyroidism cystic fibrosis sickle cell disease phenylketonuria medium chain acyl-CoA dehydrogenase deficiency (MCADD) maple syrup urine disease (MSUD) isovaleric acidaemia (IVA) glutaric aciduria type 1 (GA1) homocystinuria (pyridoxine unresponsive) (HCU)
most common congenital infection in the UK.
Cytomegalovirus
The major congenital infections encountered in examinations are
rubella, toxoplasmosis and cytomegalovirus
Features of Rubella infection?
Sensorineural deafness
Congenital cataracts
Congenital heart disease (e.g. patent ductus arteriosus)
Glaucoma
Features of Toxoplasmosis infection?
Cerebral calcification
Chorioretinitis
Hydrocephalus
Features of Cytomegalovirus infection?
Growth retardation
Purpuric skin lesions
Fetal alcohol syndrome features
short palpebral fissure thin vermillion border/hypoplastic upper lip smooth/absent filtrum learning difficulties microcephaly growth retardation epicanthic folds cardiac malformations
Newborn babies are relatively deficient in
vitamin K
Newborn babies are relatively deficient in vitamin K. This may result in
impaired production of clotting factors which in turn can lead to haemorrhagic disease of the newborn . Bleeding may range from minor brushing to intracranial haemorrhages
haemorrhagic disease of the newborn risk factors?
Breast-fed babies are particularly at risk as breast milk is a poor source of vitamin K. Maternal use of antiepileptics also increases the risk
all newborns in the UK are offered vitamin K, either intramuscularly or orally
true
Infantile spasms, or West syndrome, is a type of childhood epilepsy which typically presents when?
4 to 8 months of life
Infantile spasms features
characteristic ‘salaam’ attacks: flexion of the head, trunk and arms followed by extension of the arms
this lasts only 1-2 seconds but may be repeated up to 50 times
progressive mental handicap
Infantile spasms ix
the EEG shows hypsarrhythmia in two-thirds of infants
CT demonstrates diffuse or localised brain disease in 70% (e.g. tuberous sclerosis)
Infantile spasms mx
poor prognosis
vigabatrin is now considered first-line therapy
ACTH is also used
Shaken baby syndrome
This syndrome encompasses the triad of
retinal haemorrhages, subdural haematoma, and encephalopathy.
Caput succedaneum describes
oedema of the scalp at the presenting part of the head, typically the vertex. This may be due to mechanical trauma of the initial portion of the scalp pushing through the cervix in a prolonged delivery or secondary to the use of ventouse (vacuum) delivery.
Caput succedaneum sx
soft, puffy swelling due to localised oedema
crosses suture lines
Caput succedaneum mx
No treatment is needed.
A cephalohaematoma is seen as
a swelling on the newborns head. It typically develops several hours after delivery and is due to bleeding between the periosteum and skull. The most common site affected is the parietal region
Cephalohaematoma Jaundice may develop as a complication.
true
A cephalohaematoma up to 3 months to resolve.
true
