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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
Which vitamin is usually involved in refeeding syndroem?
Thiamine !!
26
Should naloxone be given in NAS babies?
No - will start withdrawing +++
27
Do opiates or benzodiazepines cause MORE teratogenicity?
Opiates - less teratogenic All others +++
28
Is breastfeeding contraindicated in NAS infants?
No - alleviate withdrawal - If hypotonic, would not feed PO anyway
29
What percentage of infants born to mothers born taking methadone develop NAS
70% - not all need treatment
30
Is hypotonicity characteristic of NAS?
No - Hypertonic ++, last thing to recover.
31
What is the main differential diagnosis of NAS?
Hyperthyroidism - also causes tremors, low grade fevers, incessant crying - Need to check maternal TRABs
32
Characteristics of RSD on X-ray
Ground glass appearance, no clear heart border ETT in situ (just below clavicles) 2 x vascular lines - arterial
33
Ground glass throughout No heart border
34
\*Add xray R) pneumothorax
R) pneumothorax with tension and not much collapse due to stiff lung
35
Bilateral chest x-rays Pneumomediastinum Short NGT
36
Overexpanded left lung - secondary to pulmonary interstitial emphysaema Mediastinal shift to right L) chest drain RUL consolidation
37
Patchy areas of collapse and consolidation, over inflation and underinflation Developing chronic lung disease
38
Over expansion of bases Fibrosis of apices - chronic lung disease - eventually form bullae ET too low (at carina
39
What pushes oxygen dissociation curve to right? (reduced affinity)
Adult Hb
40
What pushes oxygen dissociation curve to right? (reduced affinity)
Adult Hb High 2-3 DPG (eg - in anaemia due to chronically reduced O2) Higher temperature High H+++
41
Characteristics of Human Milk Oligosaccharides (x 6)
- 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
42
What is the major whey protein in breast milk?
Lactoferrin
43
Mechanism of action of lactoferrin
Iron transporter - binding iron and enabling passage across mucosal barrier 6 x higher concentration in colostrum than mature milk Gut trophic, anti-inflammatory
44
Does lactoferrin prevent NEC?
No but may prevent late onset sepsis
45
What effect do high concentrations of lactoferrin in colostrum have on gut permeability?
decreases gut permeability
46
How does lactoferrin work in immune function?
Bacteriostatic - sequesters iron thereby inhibiting viral and bacterial replication
47
Facts about gentamicin in the new born ( x )
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)
48
List bacteriotstatic antibiotics (x 4)
Chloramphenicol Erythromycin Sulphonamides Tetracyclines
49
List bacteriocidal antibiotics (x 3)
Pencillins B-lactams Aminoglycocides
50
What type of cerebral palsy is most common in prematurity without RDS / asphyxia but with apnoeas / feed intolerance?
Spastic diplegia
51
Risk factors for cerebral palsy (x 7)
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
What type of cerebral palsy is most common in kernicterus?
Athetoid cerebral palsy -
53
What type of cerebral palsy is most common in cerebral infarction / neonatal stroke\>
Hemiplegia
54
What type of cerebral palsy is most common in periventricular flair / severe HIE?
Spastic quadriplegia
55
Does BCG vaccine prevent pulmonary TB?
False - prevents disseminated TB - Does not prevent mycobacterium avium
56
If the mother has active TB, how do we manage a newborn?
Treat with isoniazid x 6 months + vaccinate with BCG
57
Where is the standard site for BCG vaccination?
INTRADERMAL - not intramuscular - either right or left
58
High risk TB regions?
South east Asia South America China / Hong Kong Africa Russia Solomon Islands (rest of pacific OK)
59
Contraindications to BCG vaccination?
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
What is the transmission rate of HIV in pregnancy to foetus?
15-25%
61
What marker is the most predictive for vertical HIV transmission?
Viral load (NOT CD4 count)
62
When should mothers who are HIV + start antiretroviral treatment in pregnancy if they have undetectable viral load?
at 20 weeks
63
When does vertical transmission of HIV occur?
During pregnancy During Labour (50% !!) During breast feeding
64
How effective is ART for reducing vertical transition?
Very effective Only 1% max if viral load undetectable
65
How long should infants receive ART post delivery?
If maternal viral load is undetectable - 4-6 weeks
66
Is breastfeeding contraindicated in HIV?
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
Is PJP prophylaxis recommended for babies born to mothers who are HIV positive?
Not routinely - only if risk of transmission is high - Now usually only if infant is HIV pos
68
What is the possible side effect of using protease inhibitors in infants?
Lipodystrophy Mitochondrial dysfunction possible in NRTIs
69
Whats is a common presentation of HIV in infancy?
Recurrent bacterial infections and FTT - NOT recurrent candidiasis
70
What is gold standard of testing HIV status in infants?
Viral Load - watch antibody levels drop to negative following treatment
71
Where should the UA be? on CXR?
T6-T9
72
Where should the UV be on CXR?
T10
73
Where should the ET tube be on xray?
T2 (between clavicles)
74
What is the survival rate of babies born at 24 weeks ? And 25 weeks?
70% 25 weeks - 80%
75
What is the benefit of a repeat course of antenatal steroids one week after the first course?
Reduced risk of lung disease Can cause reduced HC
76
What is the evidence for inhaled nitric oxide in extreme preterm babies? (short and long term?)
Short term - improved oxygenation Long term - no proven benefit in outcomes
77
What are the levels of the abdominal arterial branches of the aorta?
Coeliac axis T12/L1 Superior mesenteric + renal arteries - L1/L2 Inferior mesenteric - L3/L4
78
What is the xray findings of duodenal atresia?
Double Bubble
79
What is the finding of repeated vomiting of gastric contents?
Hypochloraemia, hypokalaemic metabolic acidosis
80
What percentage of babies with duodenal atresia will also have trisomy 21?
30%
81
Term baby having recurrent apnoeas - what diagnosis should you consider?
Apnoeas are seizures unless proven otherwise
82
What is the first line treatment of neonatal seizures?
Phenobarbitone More seizures - more impairment
83
What percentage of babies with a perinatal stroke will have normal developmental outcomes?
1/3 will be normal 50% will have hemiplegic cerebral palsy
84
What is the main cause of strokes in neonates?
Embolic from the placenta
85
What level of ROP is this?
Grade 3 - clear ridge - Friable small vessels - Unvascularised vessels
86
Causes of chorioretinitis
Toxoplasmosis, CMV, syphillis
87
Inheritance pattern of retinoblastoma
Autosomal dominance
88
Treatment options for ROP?
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
What prophylactic medication can reduce Grade III/IV IVH ?
Indomethacin - reduced grade 3/4 IVH but no change in long term outcomes
90
Is antenatal dexamethasone or betamethasone reduce IVH more?
Both the same - both reduce it
91
\* xray of big heart + plethoric lung fields \* + need for operation timing
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
What is the classic presentation and appearance of pulmonary atresia with intact ventricular septum?
Oligaemic lung fields Large heart Coronary fistulae Normal anterior mediastinum
93
Which prostaglandin maintains ductus arterosis ?
E1 \*\* E2 constricts the duct \*\*
94
Side effect of frusemide?
Metabolic Hypokalamic Alkalosis - Lose K --\> lose H+
95
Which diuretic should be paired with frusemide to prevent loss of K+?
Spironolactone (K+ sparing, not thiazide)
96
What is the chance of offspring of child with CHD having a CHD?
3%
97
How do you correct metabolic alkalosis caused by frusemide?
Need to give IV K+ + Na to prevent seizures
98
What ECG finding would suggest a VSD is of significant size at day 7 of life?
T-waves should flip by day 7 IF persistent in V3, suggests RV strain
99
What are omphalocoeles associated with?
Beckwith-Wiedermann lots of other things! (60%) membrane covering bowel, normal bowel inside Umbilical cord is centre of membrane
100
What is gastroschisis associated with?
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
Which sided lesions of diaphragmatic hernia has a higher mortality?
Right - especially if the liver is in the chest
102
What is the survival rate of CDH in live births?
60-70% of LIVE BIRTHS 30% are stillborn
103
Is CHD usually associated with other chromosomal abnormalities?
No - usually isolated
104
If a baby is on oscillator ventilation is hypercapnic, how would you normalise the gas?
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
Lung lobectomy is the treatment of choice for what congenital conditions?
CAM ?? Congenital lobar emphyseaema
106
Gram positive bacilli causing neonatal infection? + treatment
Listeria monocytogenes - ampicillin / amoxicilliin (30% resistant to benpen) - synergy with gentamicin
107
Where do mothers get Listeria?
Unpasturised milk, soft cheese, prepared meats (hot dogs, deli meat, pate) raw vegetables (unwashed)
108
Whats it he classic rash of listeria infection?
Erythematous with small pale nodules
109
What condition has a blueberry muffin rash?
TORCH infections - CMV
110
Is selective head cooling better than total body cooling?
No - both similar
111
Describes the zones of the retina in classification of retinopathy of prematurity
112
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
Bell stage 1A NEC = Suspected NEC
113
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
Bell 1B - suspected NEC
114
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
Bell stage IIA - Proven NEC\< mildly ill
115
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
Bell stage IIB = Proven NEC - moderately Ill
116
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
Bell stage 3A - Advanced NEC - severely ill, bowel intact
117
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
Bell stage 3B - Advanced NEC - severely ill bowel perforation
118
What is a Bochdalek diaphragmatic hernia?
Posteriolateral Occures 6 weeks gestation Most common (75%) L (85%) \>R (15%)
119
What is a Morgagni diaphraghmatic hernia?
Anterior Less common (23%) Later presentation Other hernia = hiatus = 2%

Dana's Exam Learning. (17 decks)

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