Fetus and Newborn Flashcards
Define low birth weight
infant whose birth weight is < 2500 g
Define very low birth weight
Infant whose birth weight is < 1500 g
What are the percentiles for SGA, AGA and LGA?
SGA < 10%
LGA >90%
AGA between 10-90%
What is the definition of a preterm birth
born before the last day of the 37th week
What is the definition of a term birth
born between 38 and 42 weeks
What is the definition of post term birth
born after 42 weeks
What is the definition of perinatal death
death occurring between 28th week to 28th day of life
What maternal factors are most common in infants with higher mortality rates
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
What type of infants have higher mortality rates?
boys
multiple births
preterm infants
What are the risk factors for prematurity?
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
What are some independent risk factors for increased mortality in pre-term infants?
male congenitial anomalies 5 minute apgar < 4 no antenatal steroids persistent bradycardia at 5 minutes hypothermia IUGR
What is the definition of IUGR
fetus is less than the 10th percentile for growth for gestational age
usually due to placental abnormalities or ischemic placental disease
What is the leading cause of infant death in the US?
congenital malformation, 25%
What is the appropriate number of vessels for an umbilical cord?
2 arteries and 1 vein
What is an abnormal number of umbilical vessels associated with and what should be checked?
most common is a single artery, 30% of these will have a congenital anomaly, trisomy 18 is the most common
consider renal US
What is chorioamnionitis and what should be done for an infant whose mother has chorioamnionitis?
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
In multiple gestations what sort of placentas and membranes can take place? What type of twins is each associated with?
monochorionic diamniotic: usually identical
dichorionic diamniotic: usually fraternal
What happens with the artery of one twin supplies a cotyledon that is then drained by the vein of the other twin
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
When is universal screening for GBS done?
Between 35-37 weeks
Who should receive intrapartum prophylaxis?
- 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
What medication is given for GBS prophylaxis
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
What should be done to infants born of Mom who should get GBS prophylaxis?
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
What are the confirmatory tests for premature rupture of membranes?
Check pH, 7-7.3 is consistent with amniotic fluid
check for ferning
What is the management for Premature rupture of membranes?
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
When should an infant be delivered when their has been premature rupture of membranes?
If there is infection, infant must be delivered ASAP
What are the signs of severe pre-eclampsia
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
How is severe pre-eclampsia treated?
labetalol, hydralazine
magnesium
immediate delivery of the infant
What can hypermagnesemia cause in the infant?
respiratory depression, lethargy, flaccidity, failure to pass meconium, hyporeflexia, poor feeding
treat with supportive care
can use IV calcium and diuresis
What is HELLP syndrome
hemolysis, elevated Liver enzyme and Low Platelets
What is the incidence of malformations most related to in an infant of a diabetic mother?
degree of hyperglycemia prior to conception
What are the glucose goals during pregnancy for a diabetic mother?
A1c < 6,
fasting sugars 60-100
1 hr post prandial 100-140
What is the simplest screening method to detect IUGR
fundal height
What is non stress testing and what is considered reactive and non reactive
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
What is a biophysical profile?
- fetal movement by NST
- fetal tone
- fetal reactivity
- fetal breathing
- amniotic fluid volume
When does a biophysical profile indicate that the infant is not doing well?
Each item is scored 0-2.
score < or equal to 4 = emergent delivery
What is the contraction stress test
fetal heart rate in response to oxytocin or breast stimulation.
3 contractions 1 min each over 10 minutes is normal
Name the non-reassuring fetal patterns
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
What should be done if infant has non reassuring fetal patterns?
fetal scalp stimulation
check fetal pH
if pH < 7.2 : immediate delivery (normal >7.25)
What are ominous patterns of fetal heart rate?
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
Causes of fetal tachycardia
fetal hypoxia maternal fever hyperthyroidism maternal or fetal anemia chorioamnionitis fetal tachyarrhythmia prematurity drugs (atropine, terbutaline, hydroxyzine)
Causes of fetal bradycardia:
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
Which lobe in the liver has the higher oxygen concentration
The left as the venous supply is all from the umbilical vein
blood goes from umbilical vein to ductus venous to inferior vena cava
What three changes happen in the lung at birth
mean pulmonary artery pressure drops
blood flow increases
pulmonary vascular resistance increases
What cells make surfactant?
Type II cells
How is an Apgar score calculated?
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
How do you calculate the size of the endotracheal tube for a neonate?
< 1.0 kg -2.5 mm tube diameter
1-2 kg - 3 mm
> 2 kg - 3.5 mm
Name the progression of ear formation used to determine gestational age of a newborn.
flat shapeless 24-33 weeks
superior incurving 34-35 weeks
upper 2/3 incurving 36-38 weeks
well-defined incurving to lobe > 39 weeks
Name the progression of sole creases used to determine gestational age of a newborn
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
Name the progression of lanugo used to determine gestational age of a newborn
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
What are some signs of hypothyroidism in a newborn
umbilical hernia, prolonged jaundice and persistent posterior fontanelle
What is craniotabes and what causes it?
soft areas away from the fontanelle
in utero compression
also associated with hydrocephalus, rickets and syphilis
If the sagittal suture closes early what head shape results?
Scaphocephaly
If the coronal suture closes early what head shape results?
brachycephaly
if the lambdoid or single coronal suture closes early what head shape results
plagiocephaly
if the metopic suture closes early what head shape results
keel shaped forehead, trigonocephaly
What is the management of crainosynostosis
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
What is a caput succedaneum
edema with sometimes is ecchymotic crosses suture lines, crosses the midline located above the periosteum resolves over several days may make neonatal jaundice worse
What is a cephalohematoma
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
What can an occipital cephalohematoma also look like and what should be done to distinguish between the two
occipital cephalohematomas are rare
encephalocele-transilluminate, is pulsatile and is associated with an underlying boney defect
need US or CT to distinguish the two.
What is a subgaleal hemorrhage
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
Name the three types of skull fractures and their significance
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.
What is a white pupillary reflex and what is it associated with?
leukocoria
chorioretinitis, retinopathy of prematurity or retinoblastoma
What does a congenital cataract look like and what are they associated with?
blackish-gray opacity that interferes with the retina
rubella, CMV or toxoplasmosis
What is the difference between epithelial pearls, Epstein pearls and ranula?
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
What should be done with a short frenulum
should not be surgically cut unless, interferes with feeding or speech
What should be done about Natal teeth
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
Where are thyroglossal duct cysts and where are brachial cysts located?
thyroglossal duct: ventral midline
brachial cleft: anterior margin of the sternocleidomastoid muscle
What is erb’s palsy and what is it associated with?
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
What is klumpke palsy
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
What happens if there is damage to the thoracic nerve sympathetic fibers?
Horners: ptosis, miosis and anhidrosis
delayed pigmentation of the iris
When should a neonatal heart murmur be investigated?
- accompanied by cyanosis
- accompanied by evidence of poor perfusion
- louder than a grade II
- accompanied with tachypnea
- persists after the 2nd day
What is diastasis recti
midline gap between abdominal rectus muscles
most noticeable with crying the improves in a year
what is an omphalocele
mass outside the body of abdominal contents covered with a membrane
often associated with a genetic syndrome
What is a gastroschisis
abdominal wall defect lateral to the umbilicus resulting in the intestines being outside of the abdomen
NO MEMBRANE
What is prune belly syndrome
absence of anterior abdominal wall muscles with urinary tract abnormalities and cryptorchidism
What is considered delayed separation of the umbilical cord and what is it associated with?
> 1 month
leukocyte adhesion deficiency
What penile length in a newborn boy is abnormal?
< 2.5 cm
What is a contraindication to elective circumcision?
Hypospadias
What should be done if Mom is surface antigen positive for Hep B
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.
When should an newborn’s glucose be checked?
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
When should hypoglycemia be intervened upon and what is the intervention?
glucose < 40 in the first 24 hours
< 50 after 24 hours
treatment with bolus of 200 mg/kg of 10% glucose
what are the complications to an infant of a diabetic mother
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
How is the risk different to the infant if the mother has gestational diabetes?
are at increased risk for everything except congenital abnormalities and future obesity/diabetes
What are the congenital anomalies found in an infant of a diabetic mother?
VSD neural tube defects gastrointestinal atresia situs invertus urinary tract anomalies spinal agenesis associate with caudal regression syndrome microcolon
What is transient tachypnea of the newborn and how is it treated?
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
What is persistent pulmonary hypertension of the newborn
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
What are the most common identified etiologies of persistent pulmonary hypertension
meconium aspiration pulmonary infections birth asphyxia hypothermia RDS congenital diaphragmatic hernia polycythemia maternal use of NSAIDS or SSRI sepsis pulmonary hypoplasia hypoglycemia
How is persistent pulmonary hypertension managed?
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
What is the delivery room management of an infant with possible meconium aspiration
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
How is meconium aspiration treated?
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
What is interstitial pulmonary fibrosis or Wilson-mikity syndrome
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
What are some treatment options of closure of a PDA?
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
When should indomethacin not be used for PDA closure?
NEC serum creatinine > 1.6 hourly urine output < 1 ml/kg bleeding diathesis platelet count < 50,000
Who are more likely to have meconium plugs
small left colon syndrome cystic fibrosis hypothyroidism rectal aganglionosis maternal drug abuse hypermagnesemia from maternal pre-eclampsia
What are the symptoms of meconium ileus?
bilious vomiting, abdominal distension, failure to pass meconium
What can be seen on XR with meconium ileus?
distension of proximal bowel, right lower abdomen with a soap bubble appearance.
intraabdominal calcifications which indicates prior meconium peritonitis
How is meconium plug treated? how is meconium ileus treated?
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
What is the treatment for NEC?
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
When does normal physiologic jaundice occur?
Day 3-4
What should be done if jaundice continues beyond 10-14 days
check new born screen
check for hypothyroidism, galactosemia, evaluate weight gain, color of stools, feeding history
What are risk factors for severe hyperbilirubinemia
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
What is crigler-Najjar syndrome type 1 and type 2?
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
What to consider if jaundice occurs after the first week
breast milk jaundice sepsis galactosemia hypothyroidism CF congenital atresia of biliary ducts neonatal hepatitis spherocytosis congenital infection hemolytic anemia (G6PD, pyruvate kinase deficiency)
What are the features of acute and chronic kernicterus
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
what are the levels to initiate phototherapy for low risk, > 38 weeks no risk factors.
24 hours: 12
48 hours: 15
72 hours: 18
what are the levels to initiate phototherapy for intermediate risk infants ( term with risk factors or 35-37 6/7 with no risk factors)
24 hours: 10
48 hours: 13
72 hours: 15
what are the levels to initiate phototherapy for high risk infants ( 35-37 6/7 with risk factors)
24 hours: 8
48 hours: 11
72 hours: 13.5
What are some of the complications of exchange transfusion?
thrombocytopenia and coagulopathy portal vein thrombosis NEC electrolyte abnormalities (hypo k, hypocalcemia) Graft vs host reactions infections arrythmias
What can reduce the need for exchange transfusion in infants with severe hemolytic disease due to Rh or ABO incompatibility
IVIG
what are the levels to initiate exchange transfusion for low risk, > 38 weeks no risk factors.
24 hours: 19
48 hours: 22
72 hours: 24
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)
24 hours: 16.5
48 hours: 19
72 hours: 21
what are the levels to initiate phototherapy for high risk infants ( 35-37 6/7 with risk factors)
24 hours: 15
48 hours: 17
72 hours: 18.5
