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Dana's Exam Learning. > Neonatal and Perinatal Medicine > Flashcards

Neonatal and Perinatal Medicine Flashcards

1
Q

Features of necrotising enterocolitis on xray - what is pneumotosis

A

Portal venous gas pneumotosis coli “ train tract” - intraluminal gas - sub mucosal and subserosal gas (nitrogen and hydrogen produced by gas forming bacteria)

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2
Q

Classical triad of NEC

A

Abdominal distension, bloody stools, bilious aspirates

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3
Q

Causes of NEC

A

Multifactorial - immaturity / very low birth weight - poor barrier function – bacterial translocation and mucosal damage –> NEC Ischaemia, infection, formula feeding, anaemia, toxins, bacterial overgrowth (microbial dysbiosis)

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4
Q

Good postnatal bacteria (Term babies)

A

Lactobacilli, bifidobacteria

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5
Q

Bad postnatal bacteria

A

Gram negatives - E.coli, Klebsiella, clostridia - major determinant of necrosis, ischaemia

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6
Q

Why do we give probiotics to preterm babies

A

Non-pathogenic bacteria to improve outcome Bifidobacterium + lactobacillus reduced incidence of NEC (0.26-0.93) CI ANZ studies Also reduce mortality

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7
Q

Who needs NEC surgery?

A

20-50% require surgery Perforation, abdominal mass Form ileistomy + closure 4-6 weeks - contrast pre-closure

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8
Q

How much bowel does a term baby have?

A

Length of small intestine doubles in 3rd trimester - adapts and rapidly evolves 2.5M of small bowel in term baby

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9
Q

Minimum bowel lengths required for survival post neonatal bowel resection? - + outcome predictions in babies with short gut syndrome

A

>25cm with ileocaecal valve (slows down transit time) >40cm without ileocaecal valve Outcome predicted by residual length, % of calories tolerated enterally at 12 weeks cGA and presence/abscence of ileocaecal valve

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10
Q

What is the strongest stimulus for postnatal closure of the ductus arteriosis in a term infant?

A

Increased systemic oxygen saturation

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11
Q

In utero, what percentage of the RV output goes through the lungs?

A

13%

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12
Q

In utero, what does the right ventricle mainly supply?

A

lower 2/3 of the body with low O2 blood (70%) through pulmonary artery and ductus arteriosis to the descending aorta

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13
Q

In utero, what does the Left ventricle mainly supply?

A

Upper 1/3 of the body (brain) with higher oxygenated blood shunted from umbilical vein through ductus venosis into IVC, across RA through foramen ovale into LA –> LV –> aortic arch (sO2 ~80%)

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14
Q

What is the strongest stimulus for postnatal closure of the ductus arteriosis in a term infant?

A

Increased systemic oxygen saturation + reduced flow through shunt due to decreased pulmonary vascular resistance

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15
Q

Causes of prolonged jaundice

A

Breast-feeding jaundice (Dx of exclusion) - prolonged when over 14 days - FBC, SBR

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16
Q

Signs of congenital hypothyroidism (x 5)

A

Prolonged jaundice Poor feeding / suck Bradycardia Constipation Large anterior fontanelle

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17
Q

What cause of hypothyroidism is missed on newborn screening?

A

* NBST only detects elevated TSH, won’t detect central hypothyroidism *

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18
Q

Effect of caffiene in preterm neonates

A

Reduces central apnoea Decreases incidence of chronic lung disease Increases disability - free survival reduces severe ROP Reduced cerebral palsy and cognitive delay No long term significant

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19
Q

What is the sats target for preterm babies for overall survival?

A

91-95% (any higher or lower may cause increased death)

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20
Q

Effect of caffeine in preterm neonates

A

Reduces central apnoea Decreases incidence of chronic lung disease Increases disability - free survival reduces severe ROP Reduced cerebral palsy and cognitive delay No long term significant

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21
Q

What is the sats target for preterm babies for overall survival?

A

91-95% (any higher or lower may cause increased death) - more likely to have ROP with higher sats, more likely to need O2 at 36 weeks, BUT - high sats are good for NEC and treatment of PDA

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22
Q

Late preterm (34-36 weeks) - risk of CP

A

Associaed with worse neurodevelopmental milestones at 2 yrs - brain doesn’t finish developing (very ruggaed at term) - 3 x greater risk of CP than term babies

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23
Q

What kind of ventilation should you use in babies with congenital diaphragmatic hernia?

A

Ventilate as gently as possible - use conventional mechanical ventilation initially - lung hypoplasia

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24
Q

Characteristics of Refeeding syndrome

A

Hypophophataemia Hypokalaemia Hypercalcaemia More likely in pre-term and SGA due to placental insufficiency Usually in first 5 days +/- Thiamine deficiency Increases risk of death, worse in SGA, under 1000g Constellation of fluid and electrolyte dysregulation that occurs on initiation of enteral / parenteral nutrition following a period of malnutrition / starvation

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25
Q

Which vitamin is usually involved in refeeding syndroem?

A

Thiamine !!

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26
Q

Should naloxone be given in NAS babies?

A

No - will start withdrawing +++

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27
Q

Do opiates or benzodiazepines cause MORE teratogenicity?

A

Opiates - less teratogenic All others +++

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28
Q

Is breastfeeding contraindicated in NAS infants?

A

No - alleviate withdrawal - If hypotonic, would not feed PO anyway

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29
Q

What percentage of infants born to mothers born taking methadone develop NAS

A

70% - not all need treatment

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30
Q

Is hypotonicity characteristic of NAS?

A

No - Hypertonic ++, last thing to recover.

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31
Q

What is the main differential diagnosis of NAS?

A

Hyperthyroidism - also causes tremors, low grade fevers, incessant crying - Need to check maternal TRABs

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32
Q

Characteristics of RSD on X-ray

A

Ground glass appearance, no clear heart border ETT in situ (just below clavicles) 2 x vascular lines - arterial

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33
Q
A

Ground glass throughout No heart border

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34
Q

*Add xray R) pneumothorax

A

R) pneumothorax with tension and not much collapse due to stiff lung

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35
Q
A

Bilateral chest x-rays Pneumomediastinum Short NGT

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36
Q
A

Overexpanded left lung - secondary to pulmonary interstitial emphysaema Mediastinal shift to right L) chest drain RUL consolidation

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37
Q
A

Patchy areas of collapse and consolidation, over inflation and underinflation Developing chronic lung disease

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38
Q
A

Over expansion of bases Fibrosis of apices - chronic lung disease - eventually form bullae ET too low (at carina

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39
Q

What pushes oxygen dissociation curve to right? (reduced affinity)

A

Adult Hb

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40
Q

What pushes oxygen dissociation curve to right? (reduced affinity)

A

Adult Hb High 2-3 DPG (eg - in anaemia due to chronically reduced O2) Higher temperature High H+++

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41
Q

Characteristics of Human Milk Oligosaccharides (x 6)

A
  • Only present in breast milk - Not well absorbed - largely metabolised by gut bacteria and excreted in faeces - NOT a pre-biotic - Glycans competitively block pathogen biidning to epithelial cells - GBS unable to proliferate in presences of HMO, anti-adhesive effects (also agains rotavirus) - Specific to each mother
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42
Q

What is the major whey protein in breast milk?

A

Lactoferrin

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43
Q

Mechanism of action of lactoferrin

A

Iron transporter - binding iron and enabling passage across mucosal barrier 6 x higher concentration in colostrum than mature milk Gut trophic, anti-inflammatory

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44
Q

Does lactoferrin prevent NEC?

A

No but may prevent late onset sepsis

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45
Q

What effect do high concentrations of lactoferrin in colostrum have on gut permeability?

A

decreases gut permeability

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46
Q

How does lactoferrin work in immune function?

A

Bacteriostatic - sequesters iron thereby inhibiting viral and bacterial replication

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47
Q

Facts about gentamicin in the new born ( x )

A

Bacteriocidal (at high concentrations) - through ribosomal inactivation (irreversible) 24 hour dosing decreases adaptive resistance Toxicity increases with use of loop diuretics Generally useful again gram negative (except pseudomoas) pH dependent (not so good in lungs due to low pH)

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48
Q

List bacteriotstatic antibiotics (x 4)

A

Chloramphenicol Erythromycin Sulphonamides Tetracyclines

49
Q

List bacteriocidal antibiotics (x 3)

A

Pencillins B-lactams Aminoglycocides

50
Q

What type of cerebral palsy is most common in prematurity without RDS / asphyxia but with apnoeas / feed intolerance?

A

Spastic diplegia

51
Q

Risk factors for cerebral palsy (x 7)

A

Chorioamnionitis / sepsis Maternal thyroid disease Low birth weight Multiple birth Maternal thrombophillia Other congenital abnormalities Elevated cord TNF-alpha, IL-8, IL-6, IL 1 - pro-inflammatory cytokines

52
Q

What type of cerebral palsy is most common in kernicterus?

A

Athetoid cerebral palsy -

53
Q

What type of cerebral palsy is most common in cerebral infarction / neonatal stroke>

A

Hemiplegia

54
Q

What type of cerebral palsy is most common in periventricular flair / severe HIE?

A

Spastic quadriplegia

55
Q

Does BCG vaccine prevent pulmonary TB?

A

False - prevents disseminated TB - Does not prevent mycobacterium avium

56
Q

If the mother has active TB, how do we manage a newborn?

A

Treat with isoniazid x 6 months + vaccinate with BCG

57
Q

Where is the standard site for BCG vaccination?

A

INTRADERMAL - not intramuscular - either right or left

58
Q

High risk TB regions?

A

South east Asia South America China / Hong Kong Africa Russia Solomon Islands (rest of pacific OK)

59
Q

Contraindications to BCG vaccination?

A

Immunocompromised (drug-induced or disease) HIV positive Generalised skin infections Positive Mantoux/Quantereron and under 8 months Mother received anti-TNG Tx in pregnancy (delay)

60
Q

What is the transmission rate of HIV in pregnancy to foetus?

A

15-25%

61
Q

What marker is the most predictive for vertical HIV transmission?

A

Viral load (NOT CD4 count)

62
Q

When should mothers who are HIV + start antiretroviral treatment in pregnancy if they have undetectable viral load?

A

at 20 weeks

63
Q

When does vertical transmission of HIV occur?

A

During pregnancy During Labour (50% !!) During breast feeding

64
Q

How effective is ART for reducing vertical transition?

A

Very effective Only 1% max if viral load undetectable

65
Q

How long should infants receive ART post delivery?

A

If maternal viral load is undetectable - 4-6 weeks

66
Q

Is breastfeeding contraindicated in HIV?

A

In developed countries - benefit outweights risk In developed countries - contraindicated but virus is destroyed by gastric acid Mixed feeding increases risk due to formula interfereing with mucosal barrier increasing risk of transmission

67
Q

Is PJP prophylaxis recommended for babies born to mothers who are HIV positive?

A

Not routinely - only if risk of transmission is high - Now usually only if infant is HIV pos

68
Q

What is the possible side effect of using protease inhibitors in infants?

A

Lipodystrophy Mitochondrial dysfunction possible in NRTIs

69
Q

Whats is a common presentation of HIV in infancy?

A

Recurrent bacterial infections and FTT - NOT recurrent candidiasis

70
Q

What is gold standard of testing HIV status in infants?

A

Viral Load - watch antibody levels drop to negative following treatment

71
Q

Where should the UA be? on CXR?

A

T6-T9

72
Q

Where should the UV be on CXR?

A

T10

73
Q

Where should the ET tube be on xray?

A

T2 (between clavicles)

74
Q

What is the survival rate of babies born at 24 weeks ? And 25 weeks?

A

70% 25 weeks - 80%

75
Q

What is the benefit of a repeat course of antenatal steroids one week after the first course?

A

Reduced risk of lung disease Can cause reduced HC

76
Q

What is the evidence for inhaled nitric oxide in extreme preterm babies? (short and long term?)

A

Short term - improved oxygenation Long term - no proven benefit in outcomes

77
Q

What are the levels of the abdominal arterial branches of the aorta?

A

Coeliac axis T12/L1 Superior mesenteric + renal arteries - L1/L2 Inferior mesenteric - L3/L4

78
Q

What is the xray findings of duodenal atresia?

A

Double Bubble

79
Q

What is the finding of repeated vomiting of gastric contents?

A

Hypochloraemia, hypokalaemic metabolic acidosis

80
Q

What percentage of babies with duodenal atresia will also have trisomy 21?

A

30%

81
Q

Term baby having recurrent apnoeas - what diagnosis should you consider?

A

Apnoeas are seizures unless proven otherwise

82
Q

What is the first line treatment of neonatal seizures?

A

Phenobarbitone More seizures - more impairment

83
Q

What percentage of babies with a perinatal stroke will have normal developmental outcomes?

A

1/3 will be normal 50% will have hemiplegic cerebral palsy

84
Q

What is the main cause of strokes in neonates?

A

Embolic from the placenta

85
Q

What level of ROP is this?

A

Grade 3 - clear ridge - Friable small vessels - Unvascularised vessels

86
Q

Causes of chorioretinitis

A

Toxoplasmosis, CMV, syphillis

87
Q

Inheritance pattern of retinoblastoma

A

Autosomal dominance

88
Q

Treatment options for ROP?

A

Anti-VEGEF treatment results in lower disease recurrence than laser - less recurrence in posterior zone 2 Laser reduces risk of retinal detachment from 50 –> 35% - risk of visual field loss, late detachment, glaucoma, cataracts, miopia

89
Q

What prophylactic medication can reduce Grade III/IV IVH ?

A

Indomethacin - reduced grade 3/4 IVH but no change in long term outcomes

90
Q

Is antenatal dexamethasone or betamethasone reduce IVH more?

A

Both the same - both reduce it

91
Q

* xray of big heart + plethoric lung fields * + need for operation timing

A

TGA - thin mediastinum as great vessels are on top of each other. want RV pressures to drop but not too long that LV mass drops (usually 2 weeks) for arterial switch –> usually to a septostomy + keep DA open

92
Q

What is the classic presentation and appearance of pulmonary atresia with intact ventricular septum?

A

Oligaemic lung fields Large heart Coronary fistulae Normal anterior mediastinum

93
Q

Which prostaglandin maintains ductus arterosis ?

A

E1 ** E2 constricts the duct **

94
Q

Side effect of frusemide?

A

Metabolic Hypokalamic Alkalosis - Lose K –> lose H+

95
Q

Which diuretic should be paired with frusemide to prevent loss of K+?

A

Spironolactone (K+ sparing, not thiazide)

96
Q

What is the chance of offspring of child with CHD having a CHD?

A

3%

97
Q

How do you correct metabolic alkalosis caused by frusemide?

A

Need to give IV K+ + Na to prevent seizures

98
Q

What ECG finding would suggest a VSD is of significant size at day 7 of life?

A

T-waves should flip by day 7 IF persistent in V3, suggests RV strain

99
Q

What are omphalocoeles associated with?

A

Beckwith-Wiedermann lots of other things! (60%) membrane covering bowel, normal bowel inside Umbilical cord is centre of membrane

100
Q

What is gastroschisis associated with?

A

Usually isolated but bowel inflamed 10-15% have intestinal atresia’s Often small for dates No benefit of c/s over vaginal delivery Umbilical cord is to left of midline

101
Q

Which sided lesions of diaphragmatic hernia has a higher mortality?

A

Right - especially if the liver is in the chest

102
Q

What is the survival rate of CDH in live births?

A

60-70% of LIVE BIRTHS 30% are stillborn

103
Q

Is CHD usually associated with other chromosomal abnormalities?

A

No - usually isolated

104
Q

If a baby is on oscillator ventilation is hypercapnic, how would you normalise the gas?

A

Decrease oscillator frequency - frequency controls the time allowed - therefore the lower the frequency, the greater the volume displaced and the higher the frequency, the smaller the volume displaced.

105
Q

Lung lobectomy is the treatment of choice for what congenital conditions?

A

CAM ?? Congenital lobar emphyseaema

106
Q

Gram positive bacilli causing neonatal infection? + treatment

A

Listeria monocytogenes - ampicillin / amoxicilliin (30% resistant to benpen) - synergy with gentamicin

107
Q

Where do mothers get Listeria?

A

Unpasturised milk, soft cheese, prepared meats (hot dogs, deli meat, pate) raw vegetables (unwashed)

108
Q

Whats it he classic rash of listeria infection?

A

Erythematous with small pale nodules

109
Q

What condition has a blueberry muffin rash?

A

TORCH infections - CMV

110
Q

Is selective head cooling better than total body cooling?

A

No - both similar

111
Q

Describes the zones of the retina in classification of retinopathy of prematurity

A
112
Q

What stage of NEC is this?

Systemic signs: Temp instability, apnoea, bradycardia. lethargy

Abdo signs: Aspirates, abdo distension, PR blood

Radiological signs Normal, mild ileus, mild intestinal dilation

A

Bell stage 1A NEC = Suspected NEC

113
Q

What stage of NEC is this?

Systemic signs: Temp instability, apnoea, bradycardia. lethargy

Abdo signs: Aspirates, abdo distension, FRESH PR blood

Radiological signs Normal, mild ileus, mild intestinal dilation

A

Bell 1B - suspected NEC

114
Q

What stage of NEC is this?

Systemic signs: Temp instability, apnoea, bradycardia. lethargy

Abdo signs: Aspirates, abdo distension, PR blood, absent bowel sounds, tenderness

Radiological signs intestinal dilation, ileus, pneumatosis intestinalis

A

Bell stage IIA - Proven NEC< mildly ill

115
Q

What stage of NEC is this?

Systemic signs: Temp instability, apnoea, bradycardia. lethargy, mild metabolic acidosis, thrombocytopenia

Abdo signs: Aspirates, abdo distension, PR blood, absent bwoel seounds, tenderness, RLQ mass abdominal cellulitis

Radiological signs Normal, mild ileus, mild intestinal dilation, pneumatosis intestinalis, portal vein gas +/- ascites

A

Bell stage IIB = Proven NEC - moderately Ill

116
Q

What stage of NEC is this?

Systemic signs: Temp instability, apnoea, bradycardia. lethargy, mild metabolic acidosis, thrombocytopenia, hypotension, severe apnoea

Abdo signs: Aspirates, abdo distension, PR blood, absent bwoel seounds, tenderness, RLQ mass abdominal cellulitis, peritonitis, marked distension

Radiological signs Normal, mild ileus, mild intestinal dilation, pneumatosis intestinalis, portal vein gas + ascites

A

Bell stage 3A - Advanced NEC - severely ill, bowel intact

117
Q

What stage of NEC is this?

Systemic signs: Temp instability, apnoea, bradycardia. lethargy, mild metabolic acidosis, thrombocytopenia, hypotension, severe apnoea

Abdo signs: Aspirates, abdo distension, PR blood, absent bwoel seounds, tenderness, RLQ mass abdominal cellulitis, peritonitis, marked distension

Radiological signs Normal, mild ileus, mild intestinal dilation, pneumatosis intestinalis, portal vein gas + ascites + PNEUMOPERITONEUM

A

Bell stage 3B - Advanced NEC - severely ill bowel perforation

118
Q

What is a Bochdalek diaphragmatic hernia?

A

Posteriolateral

Occures 6 weeks gestation

Most common (75%)

L (85%) >R (15%)

119
Q

What is a Morgagni diaphraghmatic hernia?

A

Anterior

Less common (23%)

Later presentation

Other hernia = hiatus = 2%

Dana's Exam Learning. (17 decks)

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