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Fetal-newborn transition Flashcards

1
Q

Requirements for cardiorespiratory transition

A 
structural maturity of lung
replacement of fetal lung fluid --> air
adequate pulmonary surfactant
onset of breathing
incrase in pulmonary blood flow
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2
Q

Embryonic maturity of lung

A

less than 5 weeks
trachea and bronchi
evidence of 5 lobes

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3
Q

Pseudoglandular lung

A

5-16 wks
airway branching x 15 generations
cuboidal cell lining

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4
Q

Canalicular lung

A

16-25 wks
airways enlarge
thinned epithelium
capillary development

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5
Q

Saccular lung

A

24-36 wks
basement membranes fuse –> future blood-gas barrier
type II cells –> surfactant

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6
Q

Alveolar lung

A

36 weeks to 2-8 years
capillaries bulge into terminal sacs
formation of septae, crests
increasing surface area

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7
Q

Immature lung histology

A

canalicular
thick blood-gas barrier
small area for gas exchange
poorly vascularized

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8
Q

Mature lung histology

A

thin blood-gas barrier
large area for gas exchange
highly vascular

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9
Q

In utero lung fluid

A

ultrafiltrate of pulmonary capillary blood
actively secrete (Cl ion transport)
250-300 ml/day
essential for fetal respiration and maintenance of FRC

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10
Q

Lung fluid in transition

A

fluid secretions slows in late pregnancy
absorption begins in labour (active transport of Na ions)
vaginal squeeze forces fluid out of lungs (not extremely significant)
cleared by capillaries and lymphatics postnatally
aided by lung distension driving fluid into interstitium

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11
Q

Transient tachypnea of the newborn

A 
Retained fetal lung fluid
increased central vascular markings
hyperaeration
evidence of interstitial/pleural fluid
prominent interlobar fissures
flat diaphragm - hyperinflated lungs
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12
Q

Embryonic maturity of lung

A

less than 5 weeks
5 lobules
trachea and bronchi

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13
Q

Canalicular lung

A

16-25 wks
airways enlarge
thinned epithelium
capillary development

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14
Q

Saccular lung

A

24-36 wks
basement membranes fuse –> future blood-gas barrier
type II cells –> surfactant

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15
Q

Fetal channels

A 
umbilical vein
ductus venosus
foramen ovale
ductus arteriosus
umbilical arteries
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16
Q

Breathing after birth

A

Onset
Reduction in pulmonary vascular resistance: crying
increased lung blood flow
increased pO2 in blood
increased blood to the LA
functional closure of foramen ovale due to LA pressure> RA
Cord clamped - increased SVR, close umbilical vessels
closed DA: usually 24-48h in term infants

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17
Q

Mature lung histology

A

thin blood-gas barrier
large area for gas exchange
highly vascular

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18
Q

In utero lung fluid

A

ultrafiltrate of pulmonary capillary blood
actively secrete (Cl ion transport)
250-300 ml/day
essential for fetal respiration and maintenance of FRC

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19
Q

Lung fluid in transition

A

fluid secretions slows in late pregnancy
absorption begins in labour (active transport of Na ions)
vaginal squeeze forces fluid out of lungs (not extremely significant)
cleared by capillaries and lymphatics postnatally
aided by lung distension driving fluid into interstitium

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20
Q

Cord clamping time

A

Effects on infant from delayed (1-2 min) cord clamping
Higher Hb at 24-48 h
Reduced Fe deficiency at 3-6 mo
increase in phototherapy for neonatal jaundice (more blood, more jaundice)
Preterm infants: reduction in rates of interventricular hemorrhage

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21
Q

Transient tachypnea of the newborn

A 
Retained fetal lung fluid
increased central vascular markings
hyperaeration
evidence of interstitial/pleural fluid
prominent interlobar fissures
flat diaphragm - hyperinflated lungs
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22
Q

Surfactant production

A

by alveolar type II cell

stored in Lamellar body, secreted and then adsorped to alveolar space

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23
Q

Surfactant composition

A

70-80% phospholipids
10% proteins - apoproteins AD immunity, BC hydrophobic membrane proteins that increase the rate at which surfactant spreads over surface
10% neutral lipids - cholesterol

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24
Q

Respiratory distress syndrome

A

preterm infant
tachypnea, retractions, grunting, cyanosis
hypoxia
hypercapnia

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25
Fetal breathing movements
rhythmic contarctions of diaphragm associated with movement of small volumes of fluid in fetal airway 1-60 min episodes increase after each maternal meal circadian rhythm, increasing at night related to maternal melatonin concentration inhibited by acute, severe hypoxia, sedatives, alcohol, PGE2
26
Onset of breathing at birth
breathing becomes regular mechanisms: sensory/chemical stimuli, removal of placental inhibitor peptide Baby must overcome: - viscosity of lung fluid - resistance of lung tissue - surface tension at air-liquid interface
27
Newborn thermal properties
Cooler environment | heat loss via conduction, convection, radiation, evaporation
28
Breathing after birth
Onset breathing Reduction in pulmonary vascular resistance: crying increased lung blood flow increased pO2 in blood increased blood to the LA functional closure of foramen ovale due to LA pressure> RA Cord clamped - increased SVR, close umbilical vessels closed DA: usually 24-48h in term infants
29
Newborn arterial gases
``` pO2: 1 h 60 , 24 h 90 O2 sat: 1 h 90, 24 h 98 O2 content, 18 then 20 pCO2 35-45 pH 7.3-7.4transition ```
30
Time course of cardiorespiratory transition
Seconds: first breath, high transpulmonary pressure, not pink Minutes: pink, regular breathing, pulmonary blood flow increases, absorption of lung fluid Hours: rising pO2, FRC established, absorption of FLF, increasing lung compliance, RR40-60 Days: remodelling of pulmonary arteries, further increase in lung compliance
31
Pseudoglandular lung
5-16 wks airway branching x 15 generations cuboidal cell lining
32
Cord clamping time
Effects on infant from delayed (1-2 min) cord clamping Higher Hb at 24-48 h Reduced Fe deficiency at 3-6 mo increase in phototherapy for neonatal jaundice (more blood, more jaundice) Preterm infants: reduction in rates of interventricular hemorrhage
33
APGAR heart rate
0 absent 1 less than 100, almost always due to lung issues > 100
34
APGAR respiratory effort
0 absent 1 slow, irregular 2 good, crying
35
APGAR muscle tone
0 limp 1 some flexion 2 active motion
36
Neonatal hypoglycemia
Glucose less than 2.6 mmol/L
37
APGAR colour
0 blue/pale 1 body pink, blue extremities 2 all pink
38
Fetus thermal properties
0.5C > mother heat transfer via placenta suppression of thermogenesis: dont waste energy on heat generation
39
Newborn thermal properties
Cooler environment | heat loss via conduction, convection, radiation, evaporation
40
Brown fat
``` mitochondria rich sympathetic stimulation: - hydrolysis of triglyceride - release of FA, glycerol - heat generated ```
41
Cold stress
36-36.5
42
Moderate hypothermia
32-36
43
severe hypothermia
less than 32 C
44
WHO warm chain
``` warm delivery room immediate drying skin to skin contact breastfeeding bathing and weighing postponed - recommended not to bathe during first 6 hours appropriate clothing and bedding mother and baby together warm transportation warm resuscitation training/awareness raising ```
45
Fetal metabolism
anabolism dominant 90-100kcal/kg/day glucose, lactate, amino acids glucose levels 70-80% maternal
46
RDS causes
1) surfactant deficiency 2) atelectasis --> V/Q mismatch, hypoventilation 3) hypoxemia + hypercarbia --> respiratory + metabolic acidosis 4) pulmonary vasoconstriction --> persistent fetal circulation 5) proteinaceous exudate
47
Symptomatic hypoglycemia
``` jitteriness, tremor, seizure, coma irritability, lethargy, stupor hypotonia, limpness apnea, cyanotic spells poor feeding hypothermia ```
48
TTN risks
precipitous delivery mtaernal diabetes maternal sedation perinatal depression
49
Retractions at birth
- neonates with increased chest wall compliance/reduced lung compliance will have increased negative intrapleural P during inspiration - worsening lung compliance before respiratory failure is apparent by blood gas abnormalities
50
Grunting at birth
vocal cords partially closed at end of expiration generates positive end expiratory pressure (PEEP) to stent open small airways, increasing ventilated areas and improving V/Q ratio
51
Head Bobbing at birth
Contractions of SCM when accessory muscles in upper thorax are recruited indicating severe respiratory distress
52
DDx neonatal respiratory distress
``` TTN RDS meconium aspiration non-pulmonary - anemia, medication, pneumothorax - congenital heart disease, malformation - persistent pulmonary HTN ```
53
aCORN respiratory score
Scores 0,1,2 Respiratory rate: 40-60, 60-80, 80 O requirement none, 50 Retractions none, mild-mod, severe Grunting none, with stimulation, continuous at rest Breath sounds on ausc: easily heard, decreased, barely heard Prematurity: >34 w, 30-34, 8 severe
54
Pneumothorax Tx
small pneumothorax: often minimally symptomatic conservative management if not underlying disease, not ventilated, minimal respiratory distress, no continuous leak Ventilated: minimize pressures (may need to increase rate) Observe signs of deterioration Consider 100% Oxygen for nitrogen washout if smaller leaks Needle aspiration Chest tube of continuous leak
55
Dx of TTN
CXR: hyperinflation, hyperaeration, flat domes of diaphragm, vascular markings in lungs, prominent interlobular fissures Tachypnea Intercostal retractions, grunting, nasal flaring: difficulty breathing, low gas exchange Hypoxia without hypercapnia Cyanotic
56
Tx TTN
self-resolved in 1-3 d respiratory support and monitoring O2 requirements usually 4 h, further assessment
57
RDS causes
lack of surfactant production/release in alveoli progressive collapse of terminal bronchiole/alveoli increased surface tension in alveolus - increased effort for inflation
58
RDS prevalence/popn
preterm male prenatal depression maternal diabetes
59
RDS prevention
antenatal corticosteroids to increase surfactant production | tocolytic agents potentially arrest preterm labour
60
TTN risks
precipitous delivery mtaernal diabetes maternal sedation perinatal depression
61
RDS Dx
CXR: ground glass, loss of cardiac silhouette, small lung volume may see atelectasis histology: hyaline membranes and collapsed air spaces tachypnea intercostal retractions, grunting, nasal flaring, difficulty breathing, low gas exchange hypoxia with hypercapnia cyanotic
62
RDS Tx
artificial surfactant varying needs of respiratory support and O2 respiratory distress will worsen if respiratory effort or support unable to prevent progressive lung collapse fluid and metabolic management
63
Pneumothorax risks
aspiration underlying lung disease high venitlatory pressures
64
Pneumothorax prevalence/popn
primarily in babies with lung disease (aspiration syndromes and RDS) receiving respiratory support, like CPAP or ventilation spontaneous pneumothorax can occur in 1-2% of health infants during initial spontaneous breaths
65
Pneumothorax Dx
present with acute increase in respiratory distress and O2 requirements Tension pneumothorax may present with sudden onset of CV collapse
66
Pneumothorax Tx
small pneumothorax: often minimally symptomatic conservative management if not underlying disease, not ventilated, minimal respiratory distress, no continuous leak Ventilated: minimize pressures (may need to increase rate) Observe signs of deterioration Consider 100% Oxygen for nitrogen washout if smaller leaks Needle aspiration Chest tube of continuous leak
67
Meconium aspiration causes
stress during delivery leads to obstruction of small airways and alveoli Presents as pneumonitis, disrupts surfactant, mechanical disruption of airway mechanical obstruction, chemical inflammation, surfactant inactivation
68
Prevalence/popn of meconium aspiration
more likely in cases of fetal distress/difficult labour usually full term infants >34 w in utero hypoxia, meconium stained amniotic fluid
69
Dx meconium aspiration
usually stained amniotic fluid CXR: atelectasis, consolidation, hyperinflation of lungs/air trapping, spontaneous pneumothorax audible grunting, severe retractions may be accompanied by persistent pulmonary HTN of newborn
70
Tx meconium aspiration
``` severe cases are life-threatening respiratory ventilator support manage pulmonary HTN monitor for pneumothorax Abx may need surfactant administration ```
71
Congenital diaphragmatic hernia causes
developmental defect (bowel loops, liver, spleen) in chest cavity
72
Prevalence/popn of congenital diaphragmatic hernia
Unilateral: 1/2200 births 80% involve left hemidiaphragm associated with lethal anomalies (16-22%)
73
Dx congenital diaphragmatic hernia
CXR: hypoplastic lungs and obvious defects | wide clinical presentation
74
Tx congenital diaphragmatic hernia
surgery
75
Sudden respiratory depression DDx
``` may occur in intubed baby DOPE dislodged obstruction pneumothorax equipment ```

NGD (16 decks)

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