Neonatal Medicine Flashcards
Neonatal care
Level 1: special care
Level 2: short-term intensive care
Level 3: long term intensive care
Causes of hypoxic-ischaemic encephalopathy
Failure of gas exchange accross the placenta
Interruption of umbilical blood flow
Inadequate maternal placental perfusion
Compromised fetus
Failure of cardiopulmonary adaptation at birth
Clinical manifestation of hypoxic ischaemic encephalopathy
Mild: irritable infant, responds excessively to stimulation, staring of eyes, hyperventilation, hypertonia, impaired feeding
Moderate: marked abnormalities of movement, hypotonic, cannot feed, may have seizures
Severe: no normal spontaneous movement or response to pain, tone in limbs, fluctuation between hypotonia and hypertonia, prolonged seizures, multi-organ failure
Mx hypoxic ischaemic encephalopathy
Respiratoy support
Anticonvulsants for seizures
Fluid restriction: transient renal impairment
Inotrope and volume support of hypotension
Monitoring of hypoglycaemia and electrolyte imbalance
Cooling effective if initiated within 6h
Prognosis hypoxic ischaemic encephalopathy
Complete recovery in mild hypoxic iscahemic encephalopathy
Good prognosis if mostly recovered by 2w
Mortality severe HIE ~ 40%
Features suggestive of birth asphyxia
Evidence of severe hypoxia antenatally, during labour/delivery
Resuscitation needed at birth
Features of encephalopathy
Hypoxic damage to other organs
No other prenatal or postnatal cause identified
Multi-organ dysfunction in hypoxic iscahemic encephalopathy
Abnormal neurological signs Seizures PPH of the newborn hypotension hypoglycaemia hypocalcaemia hyponatraemia Renal failure DIC
Soft tissue injury during birth
caput succedaneum: bruising and odema of presenting part extends beyond margins of skull bones
Cephalhaematoma: bleeding below periosteum, confined by skull sutures
Chignon: odema and bruising from ventouse
Abrasions: scalp electrodes/accidental incision during Csection
Subaponeurotic haemorrhage: diffuse boggy swelling of the scalp, blood loss can be significant
Features Brachial nerve plexus palsy during delivery
Traction to the brachial plexus nerve roots
-breech delivery
-shoulder dystocia
Upper nerve C5/6 causes Erb’s palsy
Features facial palsy during delivery
Compression against mothers ischial spine/ forceps pressure
Facial weakness on crying
Eye remains open
Usually transient
Cx prematurity
Respiratory distress syndrome Pneumothorax Apnoea and bradycardia Hypotension Patent ductus arteriosus Temperature control Hypoglycaemia Hypocalcaemia Electrolyte imbalance Osteopenia of prematurity Nutrition Infection Jaundic Intraventricular haemorrhage Periventricular leukomalacia Necrotixing enterocolitis Retinopathy of prematurity Anaemia of prematurity Iatrogenic Bronchopulmonary dysplasia Inguinal hernias
Fractures during delivery
Clavicle -typically shoulder dystocia -excellent prognosis -callus lump at clavicle after several weeks Humerus/femur -occurs at breech deliveries or dystocia -heal rapidly with immobilisation
Features respiratory distress syndrome
At delivery or within 4h of birth
Tachypnoea >60 breaths/min
Laboured breathing with chest wall recession and nasal flaring
Expiratory grunting (attempt to produce positive airway pressure)
Cyanosis
Ix respiratory distress syndrome
Typical chest Xray: diffuse granular or ground glass appearance of the lungs and air bronchogram
Mx respiratory distress syndrome
Corticosteroids prior to delivery in at risk patients reduces incidence
Oxygen, assisted ventilation, exogenous surfactant via endotracheal tube
Cx respiratory distress syndrome
pneumothorax lobar collapse bronchopulmonary dysplasia chronic lung disease of prematurity Cor pulmonale intraventricular haemorrhage
Apnoea and bradycardia in premature infants
Common until 32w gestational age
Bradycardia associated with apnoea >20-30s
Usually immaturity of centrl respiratory control
Breathing restarts with gentle physical stimulation/ caffeine stimulation
Factors predisposing preterm infants to hypothermia
large SA:V
thin heat permable skin and transepidermal water loss
Little subcut fat
often nursed naked
Cannot curl up or shiver to conserve or generate heat
Prevention of heat loss in newborns
Raise temp of ambient air in incubator Clothe including head covering Double walls of incubator Dry and wrap at birth Nurse on heated mattress
Features patent ductus arteriosus
Common in preterm infants, esp in RDS Bounding pulse Increased pulse pressure Prominent precordial impulse Systolic murmur Signs of heart failure
Mx patent ductus arteriosus
prostaglandin synthetase inhibitor .e.g. indomethacin or ibuprofen
Surgical ligation
Features septicaemia
Risk factors: PROM, GBS positive mother, maternal temperature
Typically bradycardia, desaturations
Complete septic screen including blood culture, urine culture, lumbar puncture, CRP and leucocyte count
Immediate broad spectrum Abx to symptomatic and at risk neonates
Features Nectrotising enterocolitis
Risk increases with increasing prematurity
Common in formula feeding
Presents in the first few weeks, stops tolerating feeds, bile stained vomit, abdo distention, fresh blood in stools
Xray features necrotising enterocolitis
dilated bowel loops, bowel wall edema, pneumatosis intesinalis, portal venous gas, Rigler sign, football sign
Mx Necrotising enterocolitis
Urgent IV fluid resuscitation and maintenance, parenteral feeding, broad spectrum Abx .e.g. Penicillin, metronidazole and gentamicin
Possible development of structures/adhesions, malabsorption in bowel resection
Risk factors Respiratory distress syndrome
Male Diabetic mothers C section 2nd born twin Infants <28w
Features pneumothorax newborn
More common in ventilation hence associated with RDS
Increased oxygen requirement and reduced breath sounds unilateral
Transillumination of the chest wall by bright optic light source
Urgent decompression of tension pneumothorax
Avoidance by low pressure ventilation
Intraventricular haemorrhage features
Haemorrhage in 20% of low birthweight infants
Typically in germinal matrix above caudate nucleus: fragile network of blood vessels
Usually occurs within the first 72 hours
Associated with RDS, perinatal asphyxia
Most severe form causes hemiplegia
Impairing of CSF daining: separation cranial sutures, rapidly increasing head circumference, tense fontanelle
Mx Intraventricular haemorrhage
Symptomatic relief by CSF removal via LP or ventricular tap
Ventriculoperitoneal shunt can be used for CSF drainage
Newborn retinopathy
Developing blood vessels and the junction of vascularised and non-vascularised retina
May progress to retinal detachment, fibrosis and blindness
Associated with uncontrolled use of oxygen
Features bronchopulmonary dysplasia
Infant with oxygen requirement at 36 weeks
Lung damage due to delay in maturation
Chest xray shows widespread areas of opacification with cystic changes
Progression of RDS to pulmonary interstitial emphysema
Mx bronchopulmonary dysplasia
Nutritional optimisation, oxygen supplementation and intubation as required
Corticosteroids and diuretics may improve lung function
Newborn hypoglycaemia
Onset in first 24 hours
Typically IUGR, prematurity, diabetic mothers, large for dates, hypothermic, polycythaemia, illness
Optimal blood glucose 2.6mmol/L
Lethargy, poor feeding, jitteriness, seizures, apnoea
Abnormal blood glucose: confirmed by lab
Mx neontala hypoglycaemia
Good feeding is sufficient to treat hypoglycemia
IV dextrose if necessary
Rarely diazoxide is used to suppress insulin
Features Jaundiced baby
Deposition of bilirubin in the skin: common in newborns. Typically starts with face and progresses to limbs
Causes Jaundice <24hr
Rhesus incompatibility ABO incompatibility G6PD deficiency Spherocytosis Pyruvate Kinase Deficiency Congenital Infection
Causes Jaundice 24h-2w
Physiological Breast milk jaundice Infection Haemolysis (late presentation) Bruising Polycythaemia Crigler-Najjar Syndrome
Causes Jaundice >2w
Physiological/Breast milk Jaundice Infections especially UTIs Hypothyroidism Haemolytic anaemias High GI obstruction Neonatal hepatitis Bile duct obstruction
Ix Jaundice
transcutaneous bilirubin, serum bilirubin if within 50 of treatment thresholds
Mx Neonatal Jaundice
dual emission phototherapy (450nm) with a bilirubin above 350 (plateau by day 3), and rebound bilirubin after 2 weeks. Possible exchange transfusion if phototherapy unsuccessful replacing twice the neonatal blood volume
Cx Neonatal Jaundice
kernicterus (basal ganglia damage from excess bilirubin crossing BBB causing encephalitis)
Features physiological jaundice
Inefficient bilirubin metabolism: common
High Hb concentration at birth, shorter RBC life span and inefficiency of metabolism all contribute to slower breakdown
Mild, presents at day 2-3
self resolves within first week
Features neonatal hepatitis
Bruising, poor weight gain, dark urine, pale stools
Check maternal hepatitis status
Features biliary atresia
Presents after 2-3 weeks
Dark urine, pale stools
Surgical intervention immediately
Late recognition can result in need for transplantation
Features haemolytic ABO disease newborn
Presents within 12-72 hours AB IgM antibodies do not cross the placental but IgG can Group OF mothers with A/B/AB babies Hepatosplenomegaly absent Coombs test positive
Features congenital hypothyroidism
Coarse facial features, hoarse cry, dry umbilicus
Screening at day 7 via heel prick, serum TSH and T4
Features rhesus haemolytic disease
Affected infants usually identified antenatally
Severe presentation of anaemia, hydrops, hepatosplenomegaly
Antibiotics typically to rhesus D, but may develop against Kell and Duffy blood groups
Features G6PD deficiency
X linked recessive condition
Typically mediterrean,. Middle East and African populations
Mainly affects males
Intravascular haemolysis, splenomegaly, gallstones
Heinz bodies on blood film
Mx G6PD deficiency
Avoidance of specific drugs which precipitate jaundice: Anti-malarias .e.g. Primaquine, ciprofloxacin, sulph-drug groups .e.g. Sulphonamides, sulfasalazine, sulfonylureas
Safe medications: penicillins, cephalosporins, macrolides, tetracyclines, trimethoprim
Features spherocytosis
Autosomal Dominant affecting shape of rbc
Diagnosis by spherocytes on blood film: round, lack of central pallor
Northern European populations
Extravascular haemolysis
Haemolytic crisis precipitated by infection
Osmotic fragility test is diagnostic
Features polycythaemia
Venous haematocrit >0.65
Babies typically have a high packed cell volume
Features Crigler Najjar
Autosomal Recessive
Absolute deficiency of UDP-glucuronosyl (type 1)
Type 1 do not survive to adulthood
Type 2 may improve with phenobarbital
dDx breathing difficulty in the newborn
Respiratory distress syndrome Transient tachypnoea of the newborn Meconium aspiration Birth Asphyxia Diaphragmatic hernia Laryngomalacia Tracheoesophageal fistula Pneumonia Persistent pulmonary hypertension of the newborn
Features transient tachypnoea of the newborn
Most common cause of respiratory distress in term babies
Delay in clearance of fluid in lungs: C section greater incident ? fluid not squeezed out
Respiratory distress and cyanosis
Self resolves within a few days
Chest Xray transient tachypnoea of the newborn
hyperinflation of lungs, fluid in horizontal fissure, cardiomegaly and prominent perihilar markings
Features meconium aspiration
Passage of meconium before birth, typically in post-dates
Typically causes a chemical pneumonitis
Risk factors meconium aspiration
post-dates, maternal hypertension, preeclampsia, chorioamnionitis, smoking, substance misuse
Chest Xray meconium aspiration
over inflation and heterogeneous opacification (collapse and consolidation)
Mx Meconium aspiration
Mechanical ventilation often required
Inotropic support of blood pressure and inhaled NO
Features diaphragmatic hernia
Usually diagnosed on antenatal screening
Failure to respond to resuscitation or respiratory distress
Displaced apex beat and heart sounds to right side of chest
Poor air entry on left side
Mx diaphragmatic hernia
NG tube to drain and prevent distention
Surgical repair
Cx diaphragmatic hernia
Compression can prevent lung development causing hypoplastic lungs
Newborn pneumonia causative organisms
Gram negative bacilli (E.coli, klebsiella, pseudomonas), group B strep and staphylococcus
Features persistent pulmonary hypertension of the newborn
Acute neonatal emergence
Persistence of intracardiac shunts due to high pulmonary vascular resistance
All cases before 72 hours
Usually associated with birth asphyxia, meconium aspiration, septicaemia, RDS
Worsening cyanosis, hypoxia and tachypnoea
Echocardiogram includes cardiac pathology and shows increased pulmonary pressures and tricuspid regurgitation
Mx PPH of newborn
Requires mechanical ventilation and respiratory support
Inhaled NO and potent vasodilators
Systemic BP is kept high to prevent right lieft shunting
MX neonatal conjunctivitis
Common in neonatal period
Saline cleaning allows for spontaneous resolution
Purulent discharge, infection, swelling of eyelid suggest gonococcal infection- third gen cephalosporin
Chlamydia present at 1-2 weeks- treated with oral erythromycin for 2 weeks
Features Early onset neonatal infection
Illness within 48 hours
Usually vertical transmission from mother
Prophylactic treatment if mother exhibiting signs of infection, GBS positive, PROM, prematurity
Fever and temperature instability, irritability, poor feeding, panoea, bradycardic, respiratory distress, jaundice, neutropenia, hypoglycemia, lethargy, seizures
Usually GBS, rarely listeria, klebsiella, pseudomonas
Mx Early onset infection in newborn
CRP may take 12-24 hours to increase: prophylactic antibiotics can be stopped if no CRP rise
Blood culture and inflammatory markers: consider LP
Broad Spectrum Abx .e.g. Benzylpenicillin + gentamicin
Features Late onset infection in newborn
Likely environmental agent
Onset after 48 hours
Coagulase negative staph most common
Mx late onset infection in newborn
Initially flucloxacillin and gentamicin
Neuropenum and vancomycin may be required if initial treatment resistance
Features umbilical injection
Usually umbilicus dries and separates spontaneously
Redness and inflammation suggests infection hence antibiotics are used
Granulous tissue should be ligated or treated with silver nitrate
