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Pediatric Board > Fetus and Newborn > Flashcards

Fetus and Newborn Flashcards

1
Q

Define low birth weight

A

infant whose birth weight is < 2500 g

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2
Q

Define very low birth weight

A

Infant whose birth weight is < 1500 g

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3
Q

What are the percentiles for SGA, AGA and LGA?

A

SGA < 10%
LGA >90%
AGA between 10-90%

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4
Q

What is the definition of a preterm birth

A

born before the last day of the 37th week

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5
Q

What is the definition of a term birth

A

born between 38 and 42 weeks

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6
Q

What is the definition of post term birth

A

born after 42 weeks

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7
Q

What is the definition of perinatal death

A

death occurring between 28th week to 28th day of life

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8
Q

What maternal factors are most common in infants with higher mortality rates

A

women who delay prenatal care until after 1st trimester
teens
women > 40 years of age who did not complete high school
unmarried women
women with chronic disease (HTN, DM, autoimmune disease)
smokers

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9
Q

What type of infants have higher mortality rates?

A

boys
multiple births
preterm infants

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10
Q

What are the risk factors for prematurity?

A 
previous abortion
short interpregnancy interval
assisted reproduction
placental bleeding
fetal distress
erythroblastosis
nonimmune hydrops
uterine abnormalites
tobacco use / substance use
maternal chronic disease
preeclampsia
premature rupture of membranes
chorioamnionitis
bacterial vaginosis
congenital abnormalities
polyhydramnios
Group B strep
STD
previous infant with SIDS
incompetent cervix
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11
Q

What are some independent risk factors for increased mortality in pre-term infants?

A 
male
congenitial anomalies
5 minute apgar < 4
no antenatal steroids
persistent bradycardia at 5 minutes
hypothermia
IUGR
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12
Q

What is the definition of IUGR

A

fetus is less than the 10th percentile for growth for gestational age
usually due to placental abnormalities or ischemic placental disease

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13
Q

What is the leading cause of infant death in the US?

A

congenital malformation, 25%

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14
Q

What is the appropriate number of vessels for an umbilical cord?

A

2 arteries and 1 vein

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15
Q

What is an abnormal number of umbilical vessels associated with and what should be checked?

A

most common is a single artery, 30% of these will have a congenital anomaly, trisomy 18 is the most common
consider renal US

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16
Q

What is chorioamnionitis and what should be done for an infant whose mother has chorioamnionitis?

A

maternal fever with or with out associated signs and symptoms of uterine tenderness, foul smelling amniotic fluid, maternal/fetal tachycardia
often follows prolonged rupture of membranes
infant should have culture and antibiotics even if infant is asymptomatic

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17
Q

In multiple gestations what sort of placentas and membranes can take place? What type of twins is each associated with?

A

monochorionic diamniotic: usually identical

dichorionic diamniotic: usually fraternal

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18
Q

What happens with the artery of one twin supplies a cotyledon that is then drained by the vein of the other twin

A

Twin twin transfusion
donor is very small and anemia
other twin is very large with polycythemia, possible CHF and hydrops
now a laser can be used to obliterate the connection

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19
Q

When is universal screening for GBS done?

A

Between 35-37 weeks

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20
Q

Who should receive intrapartum prophylaxis?

A
  • mom delivered baby in the past with GBS disease
  • Mom had GBS bacteriuria at any time during pregnancy
  • Positive GBS screening result
  • Unknown GBS status and
    preterm labor
    intrapartum temp > 100.4
    rupture of membranes > 18 hours
    intrapartum NAAT positive for GBS
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21
Q

What medication is given for GBS prophylaxis

A

penicillin G q 4 hours
if penicillin allergic:
and no anaphylaxis: cefazolin 2 g IV q 8 hours
If penicillin anaphylaxis: clindamycin if susceptible to both clinda and erythromycin
If not susceptible: vancomycin Ig q 8 hrs

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22
Q

What should be done to infants born of Mom who should get GBS prophylaxis?

A

Infant and mom must both be asymptomatic
If mom received prophylaxis -> observe infant for 48 hours

If mom did not receive prophylaxis (but should have), infant > 37 weeks, rupture of membranes < 18 hrs -> observe for 48 hours

or if < 37 week and rupture of membranes > 18 hours -> limited eval and observe for 48 hours

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23
Q

What are the confirmatory tests for premature rupture of membranes?

A

Check pH, 7-7.3 is consistent with amniotic fluid

check for ferning

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24
Q

What is the management for Premature rupture of membranes?

A

check lung maturity in those 32-39 weeks: lecithin / sphingomyelin ratio, phosphatidylglycerol level, lamellar body count
mature lungs will show twice as much lecithin to sphingomyelin
Delivery is recommended if lung maturity confirmed and infant > or equal to 34 weeks
if not, then expectant management with prophylactic antibiotics, steroids and tocolytics to delay labor

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25
Q

When should an infant be delivered when their has been premature rupture of membranes?

A

If there is infection, infant must be delivered ASAP

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26
Q

What are the signs of severe pre-eclampsia

A 
systolic BP > 160
diastolic BP > 110
proteinuria > 5g in 24 hours or > 3+on dipstick
oliguria < 500 cc in 24 hr
visual or mental status changes
cyanosis, respiratory distress, pulmonary edema
upper abdominal or epigastric pain
LFT abnormalities
thrombocytopenia
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27
Q

How is severe pre-eclampsia treated?

A

labetalol, hydralazine
magnesium
immediate delivery of the infant

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28
Q

What can hypermagnesemia cause in the infant?

A

respiratory depression, lethargy, flaccidity, failure to pass meconium, hyporeflexia, poor feeding
treat with supportive care
can use IV calcium and diuresis

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29
Q

What is HELLP syndrome

A

hemolysis, elevated Liver enzyme and Low Platelets

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30
Q

What is the incidence of malformations most related to in an infant of a diabetic mother?

A

degree of hyperglycemia prior to conception

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31
Q

What are the glucose goals during pregnancy for a diabetic mother?

A

A1c < 6,
fasting sugars 60-100
1 hr post prandial 100-140

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32
Q

What is the simplest screening method to detect IUGR

A

fundal height

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33
Q

What is non stress testing and what is considered reactive and non reactive

A

detecting the fetal heart rate by external methods

reactive: 2 fetal heart rate accelerations in 20 minutes (fetal survival for another week is 99%)
nonreactive: the above does not occur, poor fetal outcome in 20% of cases

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34
Q

What is a biophysical profile?

A
  1. fetal movement by NST
  2. fetal tone
  3. fetal reactivity
  4. fetal breathing
  5. amniotic fluid volume
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35
Q

When does a biophysical profile indicate that the infant is not doing well?

A

Each item is scored 0-2.

score < or equal to 4 = emergent delivery

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36
Q

What is the contraction stress test

A

fetal heart rate in response to oxytocin or breast stimulation.
3 contractions 1 min each over 10 minutes is normal

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37
Q

Name the non-reassuring fetal patterns

A

fetal tachycardia > 160
fetal bradycardia < 120
saltatory variability: baseline heart rate increase > 25 bpm
variable decelerations associated with a non reassuring pattern
late decelerations with preserved beat to beat variability

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38
Q

What should be done if infant has non reassuring fetal patterns?

A

fetal scalp stimulation
check fetal pH
if pH < 7.2 : immediate delivery (normal >7.25)

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39
Q

What are ominous patterns of fetal heart rate?

A

persistent decelerations with loss of beat to beat variability
non-reassuring variable decelerations associated with loss of beat to beat variability
prolonged severe bradycardia [< 80 for 3 min, associated with death :( ]
sinusoidal pattern
confirmed loss of beat to beat variability not associated with fetal quiescence, medication or severe prematurity

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40
Q

Causes of fetal tachycardia

A 
fetal hypoxia
maternal fever
hyperthyroidism
maternal or fetal anemia
chorioamnionitis
fetal tachyarrhythmia
prematurity
drugs (atropine, terbutaline, hydroxyzine)
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41
Q

Causes of fetal bradycardia:

A 
prolonged cord compression
cord prolapse
tetanic uterine contractions
paracervial block
epidural or spinal anesthesia
maternal seizures
rapid descent in the birth canal
vigorous vaginal examination
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42
Q

Which lobe in the liver has the higher oxygen concentration

A

The left as the venous supply is all from the umbilical vein

blood goes from umbilical vein to ductus venous to inferior vena cava

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43
Q

What three changes happen in the lung at birth

A

mean pulmonary artery pressure drops
blood flow increases
pulmonary vascular resistance increases

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44
Q

What cells make surfactant?

A

Type II cells

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45
Q

How is an Apgar score calculated?

A

Heart rate 0=absent, 1= < 100 2=>100
respiration 0= absent, 1= slow, irregular 2= good, crying
muscle tone 0= limp, 1= some flexion, 2 = active motion
reflex irritability 0= no response, 1= grimace, 2 = cough, sneeze, cry
Color 0= pale, 1= body pink, limbs blue, 2= completely pink

46
Q

How do you calculate the size of the endotracheal tube for a neonate?

A

< 1.0 kg -2.5 mm tube diameter
1-2 kg - 3 mm
> 2 kg - 3.5 mm

47
Q

Name the progression of ear formation used to determine gestational age of a newborn.

A

flat shapeless 24-33 weeks
superior incurving 34-35 weeks
upper 2/3 incurving 36-38 weeks
well-defined incurving to lobe > 39 weeks

48
Q

Name the progression of sole creases used to determine gestational age of a newborn

A

No anterior sole creases 24-31
1-2 anterior creases 32-33
2-3 anterior creases 34-35
creases cover 2/3 of the anterior sole 36-37 weeks
heel creases present 38-41 weeks
deeper creases over entire sole > 42 weeks

49
Q

Name the progression of lanugo used to determine gestational age of a newborn

A

covers entire body 22-32 weeks
absent from the face 33-37 weeks
present on the shoulders only 38-41 weeks
Non present > 42 weeks

50
Q

What are some signs of hypothyroidism in a newborn

A

umbilical hernia, prolonged jaundice and persistent posterior fontanelle

51
Q

What is craniotabes and what causes it?

A

soft areas away from the fontanelle
in utero compression
also associated with hydrocephalus, rickets and syphilis

52
Q

If the sagittal suture closes early what head shape results?

A

Scaphocephaly

53
Q

If the coronal suture closes early what head shape results?

A

brachycephaly

54
Q

if the lambdoid or single coronal suture closes early what head shape results

A

plagiocephaly

55
Q

if the metopic suture closes early what head shape results

A

keel shaped forehead, trigonocephaly

56
Q

What is the management of crainosynostosis

A

neurologic complications of isolated craniosynostosis is rare
plain xr or CT is diagnostic
treatment is usually cosmetic unless there is optic nerve compromise or increased pressure
if indicated linear craniectomy is most effective

57
Q

What is a caput succedaneum

A 
edema with sometimes is ecchymotic
crosses suture lines, crosses the midline
located above the periosteum
resolves over several days
may make neonatal jaundice worse
58
Q

What is a cephalohematoma

A

collection of blood beneath the periosteum of the outer surface of the skull due to rupture of blood vessels between the skull and periosteum
does NOT cross suture lines

59
Q

What can an occipital cephalohematoma also look like and what should be done to distinguish between the two

A

occipital cephalohematomas are rare
encephalocele-transilluminate, is pulsatile and is associated with an underlying boney defect
need US or CT to distinguish the two.

60
Q

What is a subgaleal hemorrhage

A

bleeding beneath the scalp aponeurosis
firm fluctuant swelling over the scalp extending posteriorly to the neck and / or in front of the ears, displacing the ears laterally
can have significant bleeding leading to hypotension, hyperbilirubinemia
can be first sign of hemophilia

61
Q

Name the three types of skull fractures and their significance

A

Linear: benign, no imaging if there are no neurologic deficits. If there are -> CT , follow up XR in 2-3 months to show healing and rule out leptomeningeal cyst

depressed: depressed skull deformity, most do not disrupt bone continuity, excellent prognosis if no neurologic deficits
basilar: separation of the occipital bone leading to direct brain injury, disruption of venous structures and significant bleeding in posterior fossa. Poor prognosis.

62
Q

What is a white pupillary reflex and what is it associated with?

A

leukocoria

chorioretinitis, retinopathy of prematurity or retinoblastoma

63
Q

What does a congenital cataract look like and what are they associated with?

A

blackish-gray opacity that interferes with the retina

rubella, CMV or toxoplasmosis

64
Q

What is the difference between epithelial pearls, Epstein pearls and ranula?

A

epithelial pearls: shiny white masses (retention cysts on gums)
Epstein Pearls: accumulation of epithelial cells found in the midline on the roof of the mouth at the junction of the hard and soft palate
Ranula: benign mass in the floor of the mouth (sublingual dilation of the salivary gland) should be excised

65
Q

What should be done with a short frenulum

A

should not be surgically cut unless, interferes with feeding or speech

66
Q

What should be done about Natal teeth

A

could be a supernumerary tooth or a primary tooth

if anything more than a simple pinch is required to remove it, it should be left in place

67
Q

Where are thyroglossal duct cysts and where are brachial cysts located?

A

thyroglossal duct: ventral midline

brachial cleft: anterior margin of the sternocleidomastoid muscle

68
Q

What is erb’s palsy and what is it associated with?

A

damage to the upper part of the brachial plexus, C5 and C6, results in paralysis of the shoulder with arm held internally rotated.
often associated with ipsilateral clavicle fracture
if stretched and not torn will resolve

69
Q

What is klumpke palsy

A

damage to the 7th and 8th cranial nerves in the brachial plexus
results in hand being in a claw position
responds some to physical therapy

70
Q

What happens if there is damage to the thoracic nerve sympathetic fibers?

A

Horners: ptosis, miosis and anhidrosis

delayed pigmentation of the iris

71
Q

When should a neonatal heart murmur be investigated?

A
  • accompanied by cyanosis
  • accompanied by evidence of poor perfusion
  • louder than a grade II
  • accompanied with tachypnea
  • persists after the 2nd day
72
Q

What is diastasis recti

A

midline gap between abdominal rectus muscles

most noticeable with crying the improves in a year

73
Q

what is an omphalocele

A

mass outside the body of abdominal contents covered with a membrane
often associated with a genetic syndrome

74
Q

What is a gastroschisis

A

abdominal wall defect lateral to the umbilicus resulting in the intestines being outside of the abdomen
NO MEMBRANE

75
Q

What is prune belly syndrome

A

absence of anterior abdominal wall muscles with urinary tract abnormalities and cryptorchidism

76
Q

What is considered delayed separation of the umbilical cord and what is it associated with?

A

> 1 month

leukocyte adhesion deficiency

77
Q

What penile length in a newborn boy is abnormal?

A

< 2.5 cm

78
Q

What is a contraindication to elective circumcision?

A

Hypospadias

79
Q

What should be done if Mom is surface antigen positive for Hep B

A

give hep b immunoglobulin and the hep B vaccine
infant is tested between 9-18 months for anti HBs and anti HBsAg. If anti-HBs is negative, should receive 3 additional doses of hepatitis B each 2 months apart and then retested after final dose.

80
Q

When should an newborn’s glucose be checked?

A 
routine screening is not recommended but for children who are:
infant of diabetic mother
infant of a toxemic mother
LGA
SGA
premature < 37 weeks
low birth weight < 2.5 kg
polycythemia (HCT > 70%)
birth asphyxia (1 min apgar < 5)
distress
discordant twin
symptoms
   tremors, jitteriness, irritability, high pitched or weak cry, lethargy, hypotonia, poor suck, cyanosis, apnea, tachypnea, seizures
81
Q

When should hypoglycemia be intervened upon and what is the intervention?

A

glucose < 40 in the first 24 hours
< 50 after 24 hours
treatment with bolus of 200 mg/kg of 10% glucose

82
Q

what are the complications to an infant of a diabetic mother

A 
sudden death in 3rd trimester
macrosomia (increase rate of C-section)
perinatal asphyxia
IUGR
temperature instability
hypoglycemia
hypocalcemia
hypomagnesemia
unconjugated hyperbilirubinemia
polycythemia
cardiomegaly / hypertrophic cardiomyopathy
congenital heart disease
lumbosacral dysgenesis / caudal regression
small left colon syndrome
renal anomalies / renal vein thrombosis
increased risk of diabetes / obesity later in life
83
Q

How is the risk different to the infant if the mother has gestational diabetes?

A

are at increased risk for everything except congenital abnormalities and future obesity/diabetes

84
Q

What are the congenital anomalies found in an infant of a diabetic mother?

A 
VSD
neural tube defects
gastrointestinal atresia
situs invertus
urinary tract anomalies
spinal agenesis associate with caudal regression syndrome 
microcolon
85
Q

What is transient tachypnea of the newborn and how is it treated?

A

late preterm infants 34-37 weeks
precipitous vaginal delivery or c section
failure of adequate lung fluid clearance at birth
infant has tachypnea and other signs of respiratory distress
CXR shows prominent vascular markings, fluid in the fissures, flattening of the diaphragm
resolves in 12-24 hours sometimes can last up to 72 hours
oxygen therapy

86
Q

What is persistent pulmonary hypertension of the newborn

A

pulmonary vascular resistance remain elevated
resulting in persistent right to left shunting and hypoxia that is refractory to oxygen therapy
greater oxygen saturation in the upper body than the lower body
17% are idiopathic

87
Q

What are the most common identified etiologies of persistent pulmonary hypertension

A 
meconium aspiration
pulmonary infections
birth asphyxia
hypothermia
RDS
congenital diaphragmatic hernia
polycythemia
maternal use of NSAIDS or SSRI
sepsis
pulmonary hypoplasia
hypoglycemia
88
Q

How is persistent pulmonary hypertension managed?

A

treat underlying etiology if possible
correct hypoxia often requires mechanical ventilation
inhaled nitrous oxide can be used but methemoglobinemia is a complication
sometimes requires ECMO

89
Q

What is the delivery room management of an infant with possible meconium aspiration

A

if baby is not vigorous:
intubation with direct laryngoscopy and suction meconium
if meconium retrieved, this can be repeated, if not do not repeat, if HR < 100 positive pressure ventilation
if infant vigorous -> clear secretions from nose and mouth with bulb suction or suction catheter

90
Q

How is meconium aspiration treated?

A 
chest xr may show patchy infiltrates, pneumothoraces are common
surfactant can be given
supportive care with ventilatory support
no improved outcomes with antibiotics
No steroids
91
Q

What is interstitial pulmonary fibrosis or Wilson-mikity syndrome

A

seen in infants < 1500 g with no history of RDS and born at 32 weeks or less
gradual onset of dyspnea, tachypnea and cyanosis, cough, wheezing
no fever
worsens over 3-6 weeks and persists for months
Cxr with bilateral reticular infiltrates and develop into multi cystic lesions
slowly improved over months to years

92
Q

What are some treatment options of closure of a PDA?

A

supportive care
pharmacologic closure with indomethacin or ibuprofen
percutaneous transcatheter occlusion
correct anemia

PEEP is helpful to decrease left to right shunting
Term and older infants < 6 kg can be treated symptomatically until big enough for surgery

93
Q

When should indomethacin not be used for PDA closure?

A 
NEC
serum creatinine > 1.6
hourly urine output < 1 ml/kg
bleeding diathesis
platelet count < 50,000
94
Q

Who are more likely to have meconium plugs

A 
small left colon syndrome
cystic fibrosis
hypothyroidism
rectal aganglionosis
maternal drug abuse
hypermagnesemia from maternal pre-eclampsia
95
Q

What are the symptoms of meconium ileus?

A

bilious vomiting, abdominal distension, failure to pass meconium

96
Q

What can be seen on XR with meconium ileus?

A

distension of proximal bowel, right lower abdomen with a soap bubble appearance.
intraabdominal calcifications which indicates prior meconium peritonitis

97
Q

How is meconium plug treated? how is meconium ileus treated?

A

Meconium plug: glycerin suppository, rectal irrigation or diatrizoate sodium
Ileus: diatrizoate sodium enemas, possible surgical consult if there is also volvulus, atresia or perforation
in both cases check for underlying cause
Plug: hypothyroidism, Hirschsprung
ileus: CF

98
Q

What is the treatment for NEC?

A 
bowel rest, stop all enteral feeding
NG decompression
IV fluids with correction of any electrolyte abnormalities
Antibiotics:
vanco + gent + clind
vanco + gent + metronidazole
vanco + gent + pip-tazo
isolate infant from other in NICU
treatment is usually 10-14 days
consult surgery
99
Q

When does normal physiologic jaundice occur?

A

Day 3-4

100
Q

What should be done if jaundice continues beyond 10-14 days

A

check new born screen

check for hypothyroidism, galactosemia, evaluate weight gain, color of stools, feeding history

101
Q

What are risk factors for severe hyperbilirubinemia

A 
total bili in the high risk zone
jaundice in first 24 hours of life
hemolytic disease due to immune mediated hemolysis 
gestational age 35-36 weeks
sibling who needed phototherapy
delayed bowel movement
cephalohematoma or bruising
exclusively breast fed infant who has lost > 10-12%
east Asian, greek or native American
102
Q

What is crigler-Najjar syndrome type 1 and type 2?

A

Type 1: complete absence of uridine diphosphate glucuronosyltransferase: high levels soon after birth
Type 2: depressed activity of same enzyme: levels not as elevated as Type 1. Phenobarbital can induce expression of the enzyme and decrease bilirubin

103
Q

What to consider if jaundice occurs after the first week

A 
breast milk jaundice
sepsis
galactosemia
hypothyroidism
CF
congenital atresia of biliary ducts
neonatal hepatitis
spherocytosis
congenital infection
hemolytic anemia (G6PD, pyruvate kinase deficiency)
104
Q

What are the features of acute and chronic kernicterus

A

acute:
Phase 1: occurs days 1-2 poor sucking, stupor, hypotonia, seizures
Phase 2: middle of 1st week: hypertonia of extensor muscles, opisthotonus, retrocollis and fever
Phase 3: hypertonia
Chronic:
1st year of life: hypotonia, active deep tendon reflexes, obligatory tonic neck reflexes, delayed motor skills

105
Q

what are the levels to initiate phototherapy for low risk, > 38 weeks no risk factors.

A

24 hours: 12
48 hours: 15
72 hours: 18

106
Q

what are the levels to initiate phototherapy for intermediate risk infants ( term with risk factors or 35-37 6/7 with no risk factors)

A

24 hours: 10
48 hours: 13
72 hours: 15

107
Q

what are the levels to initiate phototherapy for high risk infants ( 35-37 6/7 with risk factors)

A

24 hours: 8
48 hours: 11
72 hours: 13.5

108
Q

What are some of the complications of exchange transfusion?

A 
thrombocytopenia and coagulopathy
portal vein thrombosis
 NEC
electrolyte abnormalities (hypo k, hypocalcemia)
Graft vs host reactions
infections
arrythmias
109
Q

What can reduce the need for exchange transfusion in infants with severe hemolytic disease due to Rh or ABO incompatibility

A

IVIG

110
Q

what are the levels to initiate exchange transfusion for low risk, > 38 weeks no risk factors.

A

24 hours: 19
48 hours: 22
72 hours: 24

111
Q

what are the levels to initiate exchange transfusion for intermediate risk infants ( term with risk factors or 35-37 6/7 with no risk factors)

A

24 hours: 16.5
48 hours: 19
72 hours: 21

112
Q

what are the levels to initiate phototherapy for high risk infants ( 35-37 6/7 with risk factors)

A

24 hours: 15
48 hours: 17
72 hours: 18.5

Pediatric Board (11 decks)

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