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Obstetrics and Gynaecology > Neonatal jaundice > Flashcards

Neonatal jaundice Flashcards

1
Q

Etiology

A

1.UnConjugated
a. Physiologic
b. Pathologic
–>i. Hemolytic
Membrane
Enzyme
Hemaglobin
Immune: ABO, Ph
Non-immune: Splenomegaly, sepsis, AV malformation
–>ii. Non-hemolytic
Hematoma
Polycythemia
Sepsis
HypoT
Gilberts

  1. Conjugated (always pathologic)
    a. Hepatic
    Infectious: sepsis, TORCH, hep B
    Metabolic: galactosemia, A1AT, CF, hypoT
    Drugs
    TPN
    Idiopathic neonatal hepatitis
    b. Post hepatic
    Biliary stresia
    Choledochal cyst
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2
Q

When is jaundice visible

A
  1. When levels 85-120umol/L
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3
Q

When is jaundice more severe/prolonged

A
  1. Prematurity
  2. Acidosis
  3. Hypoalbuminemia
  4. Dehydration
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4
Q

How common is jaundice

A
  1. 60% of term infants develop jaundice
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5
Q

Onset and progression of physiologic jaundice, pathophysiology

A
  1. Onset at day 2-3 of life, resolution by day 7
  2. PathoP
    +RBC number and shortened lifestyle
    Immature glocorynyl transferase->poor conjugation
    +Enterohepatic circulation
    Decreased uptake and binding by liver cells
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6
Q

Breastfeeding jaundice

A
  1. Due to lack of milk supply->dehydration->more exagerated physiologic jaundice
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7
Q

Breastmilk jaundice, cause, progress

A
  1. 1 per 200 infants
  2. Glocorinyl transferase inhibitor in the milk
  3. Onset day 7 of life->peaks at 2-3 weeks and resolves by 6 weeks.
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8
Q

When should pathologic jaundice be considered

A
  1. When
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9
Q

Risk factors

A 
1. Maternal
Ethnic Asian
Complications during pregnancy->Rh, ABO, diabetes
Breastfeeding
2. Perinatal
Birth trauma->cephalohematom
Prematurity
3. Neonatal
DIfficulty establishing breast feeding->deH
Infection
Genetic, metabolic
Polycythemia
Drugs
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10
Q

Initial assessment of all babies with jaundice

A 
1. Assess for risk factors for jaundice and significant hyperbilirubinemia
 ?family history of hemolysis
6. Examination
Feeding
Weight
Hydration
Risks: preterm, 2 weeks
7. Identify the cause if not clear from history/examination
Total serum bilirubin
FBC + film
Blood group maternal and baby
DAT
NBST if applicable
8. Refer to pediatrician/neonatologist if results abnormal
9. Fluid management
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11
Q

If

A

Medical emergency

  1. Measure and record serum bilirubin within 2 hours
  2. Manage as per treatment graphs
  3. Neonatalogy/pediatrician review within 6 hours
  4. Commence phototherapy whilst awaiting results
  5. Do investigations
  6. Manage fluids
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12
Q

24 hours to 10 days

A
  1. Measure and record TcB or serum bilirubin w/i 6 hours
  2. Manage as per treatment line
  3. Commence phototherapy if >6 hours for results, baby has risk factors, TCB >250mmol/L or above treatment threshold, jaundice below the nipple
  4. Medical review required
  5. DO investigations if cause not obvious
  6. Manage fluids
  7. Be sure to treat underlying sepsis
  8. Arrange F/U with midwife/GP to ensure adequate oral intake
    2 weeks for term, >3 weeks for preterm
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13
Q

Prolonged jaundice management

A
  1. Usually breastfeeding related
  2. Investgate
    Total and conjugated bilirubin
    FBC + film
    Reticulocyte count
    Blood group
    DAT
    TFTs
    Review NBST
  3. Seek expert advice if +conjugated, dark urine and pale stools
  4. Fluid management
  5. Consider additional investigations
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14
Q

Signs of acute bilirubin encephalopathy

A
  1. Bilirubin toxicity in first few weeks of life
  2. Lethargic
  3. Irritable, temperature instability, opisthotonos, spasticity
  4. Apnea
  5. Hypotonia, poor sucking reflex->hypertonic, high pitched cry, seizures and coma
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15
Q

Definition and manifestations of chronic bilirubin encephalopathy

A

Clinical findings of chronic bilirubin encephalopathy include
o Athetoid cerebral palsy with or without seizures
o Developmental delay
o Hearing deficit
o Oculomotor disturbances including paralysis of upward gaze
(Parinaud’s sign)
o Dental dysplasia
o Intellectual impairment

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16
Q

Define kernicterus

A
  1. Yellow staining of basal ganglia

2. Frequently used to refer to the clinical sequelae

17
Q

When is kasai procedure best done

A
  1. Before 45-60 days of life
18
Q

Prevention of jaundice

A
  1. Early and frequent breastfeeding
  2. Blood group, Rh, Coombs test on cord blood if mothers blood group is negative or unknown
  3. Risk assessment before d/c and plan f/u
  4. Monitor all infants for jaundice 12 horly
19
Q

What is Kramer’s rule

A
  1. The level of jaundice on infant->face->trunk->arms and legs can crudely correspond to serum bilirubin level
20
Q

Infants at higher, medium and lower risk

A 
1. Higher
35-37 + risk factors
2. Medium
38 + risk factors
3. Low
38 + well
21
Q

Brief overview Mx

A
  1. Fluids
  2. Phototherapy
  3. Exchange transfusion
  4. IV immunoglobulin if hemolytic and not responding
22
Q

How does phototherapy work

A
  1. Exposure to light photoisomerises unconjugated bilirubin->+solubility->can then be excreted in feces and urine
  2. Blue light is best 460-490nm
23
Q

How to increase effectiveness of phototherapy

A
  1. +amount of skin exposed
  2. +intensity of the light
  3. Additional overhead light
  4. Closer light to baby
24
Q

Biliblanket

A
  1. Outpatient

2. Allows therapy in open cot with mum on ward

25
Q

Monitoring phototherapy and cessation

A
  1. Adequacy hydration and nutrition, continue breastfeeding
  2. Temperature
  3. Clinical improvement
  4. Potential signs of bilirubin encephalopathy
  5. Cease when SBR
26
Q

Potential complications of phototherapy

A
  1. Overheat
  2. Water loss, diarrhea->hydration
  3. Rash
  4. Parental anxiety/separation->educate and reassure
  5. Ileus->bowel motions, distention
  6. ?Retinal damage
  7. Bronzing artefact from conjugated
27
Q

Indications for exchange transfusion

A
  1. Rh disease, no transfusion in utero
  2. Cord blood Hb 80 umol/L
  3. Visible jaundice 340 and + and due to hemolysis
  4. Preterm or sick may need at lower BR
28
Q

Risks of exchange transfusion

A
  1. Apnea
  2. BradyC
  3. Cyanosis
  4. Vasospasm
  5. Air embolism
  6. Infection
  7. Thrombosis
  8. Necrotising enterocolitis
  9. Rarely death
29
Q

Monitoring following exchange transfusion

A
  1. Monitor Hb
  2. May need top up transfusion
  3. Assess for complication

Obstetrics and Gynaecology (45 decks)

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