Neonatal Flashcards
What is the current survival in % for a 24/40
70%
How is ETT insertion depth calculated
Weight + 6
What two medications should be given to mum if a preterm delivery is eminent
What is the time window
Magnesium sulphate and steroids
Within 4 hours
When are antenatal corticosteroids most useful What outcomes do they improve What do they not improve Is there any benefit to repeating When should they be repeated What hat is the gestational cut off?
If given <48 hrs prior to delivery RDS, IVH, NEC, sepsis and fetal death Maternal death, chorioamnioitis, chronic lung disease Yes- improves short term neuro benefits After 7 days 35 weeks
What does antenatal magnesium benefit
When should it be given
Neurodevelopmental outcomes- reduces CP
within 4 hours of delivery
Trisomy 21 screening
What are two things on mums bloods that make it more likely
What is seen on antenatal scan
High beta HCG
Low PAPP A
Increased nuchal translucency
Which is done earlier- CVS or amniocentesis
What is the risk of fetal loss
What is the new test for trisomies? What is the most likely cause of a false positive result
Cvs
Around 1%
NIPT- confined parental mosaicism
What are three consequences of oligohydramnios
Pulmonary hypoplasia
Talipes
Potters faces
What are 4 complications of polyhydramnios
Preterm labour
APH
Cord prolapse
Malpresentation
What defines low birth weight
What is extreme low birth weight
<2.5kg
<1kg
What is the medical term for identical twins
Monochorionic monoamniotic
Which twins run in families
Dizygotic
What sign on ultrasound scanning suggests dichorionicity
Lambda sign
What are the main 9 conditions the Guthrie card can screen for?
CF Hypothyroidism SCID PKU GALACTOSAEMIA BIOTINIDASE DEFICIENCY homocysteineurina Maple syrup urine disease Fatty acid oxidation disorders
What does the newborn hearing screen assess for
If they fail what test is done next
Oto acoustic emissions
Brain stem evoked potentials
What is the difference between ortolanis and barlows
Ortolanis- hip is out and you put it back
Barlows- can you dislocate the hip
What emergency makes brachial plexus injuries most likely What is involved in ERB palsy Klumpke palsy Complete lesion What will be seen clinically
Shoulder dystocia
ERb- c5 and 5. Waiters tip
Klumpke- c7- t1 wrist drop with reduced grip
Completec5- T1- completely flaccid with hornets syndrome in 1/3
What level should an umbilical artery catheter be at
“Umbilical vein. What does this correlate to?
Coeliac artery- t6-10
Below diaphragm- t8-9
What type of cleft palates is associated with a bifid uvula
Submucosal
Malformation- anatomy When does gut rotation normally happen How does it rotate How is it normally fixed What causes a volvulus
5weeks onwards
270 degrees anti clockwise
Ligament of trietz
Lads bands (adhesions)
Malrotation How does it present What may be seen on AXR what is the investigation of choice. What is seen? How is it managed
Episodic bilious vomiting with abdominal distension and a palpable mass
Double bubble or gas less abdo
Upper GI contract- corkscrew
Urgent surgery and de Volving
Pyloric stenosis What is seen on bloods What is characteristic about the vomiting What is the investigation of choice How are they managed- 2 stages
HypoCL hypoK metabolic alkalosis
Non bilious
Ultrasound
First resus then surgery- ramsteds pyloromyotomy
TOF
What is the most common subtype
Which is the least severe. How may it present
How are they diagnosed at birth?
Proximal atresia with a distal TOF
H type- late with brassy cough and recurrent infections
Place an NG tube then X-ray- will be coiled you in the oesophagus
What syndrome is associated strongly with duodenal atresia
What is seen on X-ray
How do they present
T21
Double bubble sign
Like a malrotation with volvulus
Ano rectal atresia
What is the difference between a high and a low lesion
What syndrome is associated
What other organ may be involved
High involves the rectum. Low is just the anus
VACTRL
kidneys
What are the two main differences between omphalocoele and gastroschisis
Omphalocoele has a peritoneal covering and is more likely associated with syndromes
Gastroschisis is the opposite!
What is the normal triad for NEC
can it happen In term babies too
What does erythema of the abdominal wall indicate
When does it normally occur
Bloody stools, abdominal distension and bilious vomits or aspirates
Yes!
Peritonitis
Week 2-3
What are the 4 main risks for NEC
What maternal antibiotic is associated with an increased risk
Enteral feeding
Bacteria
Reduced gut perfusion
IUGR or prematurity
Augmentin
Does delayed feeding reduce the risk of NEC
What are the two main things that reduce NEC
No
Breast feeding and probiotic usage
NEC
What are three late signs seen on X-ray
What antibiotic regime is used
What else is done to manage them
Pneumatosis Interstitialis
Portal venous gas
Pneumoperitoneum
Amox, metro and gent
Drip and suck
Cardioresp support
What is the mnemonic to remember lung development
When does the saccular phase start
Each- embryonic Person- pseudoglandular Can- canalicular Sprout- saccular Airways- alveolar
28 weeks
Surfactant Where is it normally produced When is it given prophylactically When else should it be given What is given
Type 2 pneumocytes
<27 weeks
Evidence of resp distress
Cryosurf
TTN
What causes it
When should it resolve
What is seen on chest X-rays
Delayed fluid clearance within the lungs
Within 48 hours
Fluid within the transverse fissure and flat diaphragms
Hyaline membrane disease What is it otherwise called What is deficient Who is most likely to get it What rarely can cause it
RDS
surfactant deficiency
Preterm babies
Congenital surfactant deficiency
Hyaline membrane disease
What is seen in chest X-ray
What ventilation settings are preferred
Ground glass appearance with multiple air bronchograms
High PEEP
What are 4 complications of RDS
Pneumothorax
Pulm HTN
Pulm haemorrhage
Chronic lung disease
Is there any evidence for inhaled nitric oxide in RDS?
No
Pulm hypertension
What is the main physiological reason why it happens
Give three mechanisms behind the development of pphn
Delayed reduction in pulmonary systemic vascular resistance
Smooth muscle hypertrophy
Obstruction
Pulmonary hypoplasia
PPHN
How does it present
What are two tell tale signs of pulmonary hypertension
What is seen on chest X-ray
Severe cyanosis and resp distress shortly after birth
Single loud s2
Wide fluctuations in o2 sats
Reduced lung markings and increased RV
Will PPHN improve with hyperoxia
What type of ventilation might be useful
No
HFOV
What is the mechanism behind inhaled nitric oxide
What is it’s half life
What are 3 side effects
What may be used if it fails
Endothelial derived relaxing factor- increases cGMP causing selective pulmonary vasodilation
3-6 seconds!
Methhaemoglobin if high concentrations or failure of ventilator
Pulmonary toxicity
Inhibition of platelets causing bleeding
Prostacyclin
Meconium aspiration
Does it occur in all MEC stained liquor
When does aspiration occur
What are 4 physiological outcomes
No- only 15%
In utero
Chemical pneumonitis
V/Q mismatch
Pulmonary hypertension
Bacterial infection
MEC aspiration
What is seen on chest X-ray
Should suctioning routinely be preformed
How should they be managed (3 things)
Coarse opacities and hyperinflation
No- only if under direct vision
Early ventilation and surfactant
If experienced- before breaths given suction
Consider antibiotics
Pulmonary haemorrhage
How does it present
What is seen on X-ray
How should they be managed (4 stages)
Acute haemodynamic instability, blood from ETT or blood elsewhere (DIC)
White out
Fluid resus, increase PEEP, fluids and diuretics and blood, surfactant
What is a bubble like chest X-ray indicative of
What are the babies at risk of
PIE
Pneumothorax
What is the definition of chronic lung disease
How many have hyper- reactive airways
What is seen on chest X-ray
> 6 weeks o2 requirement or persisting chest X-ray changes
50%
Hyperinflated with fibrosis and cysts
Why is high flow o2 not used as much as CPAP in extinction failure
What is the normal pressure of cpap used
What prongs are normally used
Higher rate of failure- likely to need CPAP anyway!
4-6 cm of H2O
Hudson prongs
What are the two main goals of ventilation and what are the three variables affecting each
Adequate oxygenation
- fi o2
- MAP
- surface area for gas exchange and diffusion
Adequate ventilation
- tidal volume
- rate
- surface area for gas exchange and diffusion.
What is NIPPV
What are the two possible settings and explain each
What does it not benefit
Using a ventilator with nasal prongs- bi level support
Synchronised- every time the baby breaths their respirations are supported
Non synchronised- pressure rise intermittently at a set pressure.
Mortality, chronic lung disease
What is the difference between SIPPV and SIMV
Which is preferred
SIPPV- synch intermittent positive pressure ventilation.
Breathing at a set rate
Extra or non triggered breaths are supported
SIMV- synch intermittent manual ventilation
Only supports breaths at the set rate and not breaths above this
SIMV
What is volume guarantee
When can you not use synchronised ventilation
What is the best ventilator mode to be used when weaning
A set tidal volume that is delivered with each breath to a set PIP
In transport settings
Pressure support ventilation
In manual ventilation if the o2 is low what steps should you preform
Increase the fio2
Increase MAP- normally increase PIP. Increase PEEP if pulm haemorrhage
Or increase I time
In manual ventilation if the co2 is high what should you do
Increase the tidal volume by increasing the PIP or reducing time on volume guarantee
Increasing the rate
In HFOV
if the o2 is low what should you do
Increase the fio2
Increase the MAP
In HFOV
if the co2 is high what should you do
Increase the amplitude
Reduce the frequency
What is the normal expected weight loss
Term babies
Preterm
Term- 10%
Preterm- 15%
What is the best way to measure neonatal tubular function
What is the formula
What is the normal value?
Fractional excretion of sodium
Urine/ serum na over urine/serum creat
<2.5%
What shifts the o2 binding curve left
What does it indicate
Less h, co temp and 2,3 DPG
HBF
Greater affinity to o2, gives up less
What does delayed cord clamping benefit (2 things)
Mortality and need for transfusion
What is the transfusion threshold for a neonate
<70 and symptomatic
What type of antibodies are involved in rhesus disease of the newborn
What are three possible triggering events
IgG
Previous delivery or miscarriage, poorly matched blood transfusions
When should anti D be given to rhesus negative mums (2 scenarios)
28 weeks and within 72 hrs of delivery of baby rhesus positive
What type of antibodies form in ABO incompatibility
Is it more or less severe than rhesus disease
IgM as the baby makes them
Less
What is the definition of polycythaemia
> 65% haematocrit
What Causes haemorrhagic disease of the newborn
Where is the most common site for bleeding to occur
Name 3 conditions that make it more likely
Vitamin K deficiency
GI
CF and alpha 1 AT def, malabsorption, biliary atresia and hepatitis
Haemorrhagic disease of newborn
What is seen on bloods
After vitamin K what is given
Prolonged PT but normal APTT
FFP
Alloimmune thrombocytopenia
What type of antibodies form and to what
How do you differentiate from maternal ITP
Can it affect the first pregnancy?
IgG
Anti hpA 1 a
Mum has normal platelets
Yes!
What defines a neonatal apnoea
What is the most common type
What is the treatment- what three other things does it benefit
Pause in breathing >20 secs
Central
Caffeine- reduces CLD, helps PDA close and some improved long term Neuro outcomes
PDA
Is there any difference between indomethacin and ibuprofen
What are 2 adverse effects
No!
Reduce renal blood flow and platelet function
Outline the physiology of retinopathy of prematurity
Too much o2 to the retina, reduced new vessel formation, release of VEGF and abnormal angiogenesis
ROP
Outline the 5 stages
What is pulse disease
What are the three zones
Is type 1 ROP good or bad?
1- fine line between vascular and a vascular portions 2- ridge “ 3- neovascularisation 4- partial detachment 5- total detachment
Dilated and torturous vessels
3- outermost 1- innermost (1 therefore worse than 3)
Bad!
Can EPO treatment increase risk of ROP
Yes!
What is the biggest risk factor for developing HIE
IUGR
HIE
What is the biggest risk factor
How does it present if mild vs severe
What is the worst prognostic factor
IUGR
Mild- irritable, hyperreactive and poor feeding
Severe- encephalopathy, seizures and posturing
Very low ph
HIE
What is the best imaging modality
What is seen
What is the management strategy. When and for how long.
MRI
Increased signal usually in the deep white matter
Therapeutic cooling to 33.5 deg. Within 6 hrs and for 72 hrs
Neonatal stroke How can it present in a term baby How many babies will have normal ND outcomes What should be used to manage seizures What form of CP will they go on to have
Apnoeas
1/3
Phenobarbitone
Hemiplegic
Is intraventricular haemarrhoge possible in term babies anatomically what occurs
In mum, what might be protective
Yes- only if there was trauma or severe asphyxia
Rupture of the germinal matrix and bleeding into the ventricles
PET
When does IVH tend to present
How do they present
Within the first few days to first week- apnoea seizure and lethargy
IVH
Whatever are the 4 stages of bleeding seen on scans
1- subependymal
2- intraventricular with no ventricular dilatation
3-“ with dilatation
4- intraparenchymal too
From what point of are the cysts of PVL seen
What is another complication of IVH
3 weeks
Hydrocephalus
What percent of blood can be lost into a sub Galeal haemorrhage?
Up to 40%
How does breast milk link to late onset vitamin k deficient bleeding
Increases risk
When could choroid plexus cysts be concerning
What else would be seen on ultrasound
Trisomy 18
Clenched fists
What blood findings will be seen in a hypoglycaemic infant of a diabetic mum
High insulin
Low ketones
Negative reducing substances in urine
Congenital toxoplasmosis Is it common? How is it spread? How does it present? Which trimester is it worst? What should mums be treated with? How long should babies be treated for How long should babies be treated for
No!
Cats or unwashed veges
Asymptomatic at birth then chorioretinitis after 2 years with widespread calcifications
1st
Spiramycin, add in pyrimethane if amino positive
12 months
Congenital rubella When is it worst to contract What is the most severe complication How does it present What are late features What test in baby is diagnostic What treatment is there for mum or baby
First trimester
Abortion
IUGR and cataracts with blueberry muffin rash. Cardiac lesions- pulm stenosis and PDA
Developmental delay and SN hearing loss
IgM
immunoglobulin to mum. Nothing for baby
CMV
What is worse- mum with primary infection or mum with recurrent infections.
How does it present
What is seen on MRI
What is the best test
When should treatment be started at birth?
What is given?
Primary
Blueberry muffin rash, chorioretinitis and SGA
Hearing loss later on.
Periventricular calcification
Urine PCR
If baby is moderately or severely symptomatic at birth- delays hearing loss
Gancyclovir
Syphillis When is transmission worst How does it present at birth If missed what can occur What test is diagnostic How is it treated and why Should mum be treated in pregnancy
Late in pregnancy
Snuffles, skin peeling with red rash, pseudoparapariesis and jaundice
Saddle nose and bossing, abnormal teeth, ID
Positive treptonemal igM
Iv penicillin for 10 days- prevents and treats
Neurosyphillis
Yes!
What is the risk to the baby if mum comes into contact with parvovirus b19
Severe anaemia leading to hydrops
What is the risk to the fetus if mum has primary varicella infection. Should she be treated
When should baby get VZIG
How does congenital varicella present
Should mum breast feed if she has active varicella
Only 2-3%- yes with VZIG
If mum exposed 5d prior or 2d post delivery
Scarring, cataracts, microcephalic and hypoplasric limbs
No!
HIV
From what point of gestation should mum be treated if found to be positive. What is the aim
Is CS necessary?
Should the baby be treated at birth
Should the baby have a BCG vaccine at birth
Is pcp prophylaxis needed for baby
Is breastfeeding contraindicated?
28 weeks- aiming for an undetectable viral load If suppressed no Yes for 4-6 weeks then test No- wait for tests first No Yes
Hep c
Can mums breast feed
Yes unless cracked nipples
What calculation is used to show the need for ECMO
What are 3 contraindications
Oxygenation index- fiO2xMAP/pao2
Grade 3/4 IVH, severe cardiac lesions, liver or kidney disease, lethal malformations
HSV
Mum has lesions at birth and baby is born by cs and well. What investigations should they have
Swabs 24-48 hrs after birth of this is a reactivation. If primary infection start acyclovir straight away
What is a pathognomonic finding on post mortem with intra utero listeria infection
If baby survives what rash might be seen at birth
Granulomatosis infantiseptica
Salmon pink papules
What is the best opiate to take while breastfeeding
Buprenorphine
What is the trisomy risk
28
40
45
28- 1:1000
40- 1:100
45-1:25
What are the calorie requirements
Term baby
Preterm
Sick preterm
100kcal/kg/day
120”
150”
When do the following features first appear in a neonate
Light reflex
Glabellar tap
Breast tissue
Light reflex- 30w
Glabellar tap-34 W
Breast tissue- 36w
