neonatology Flashcards
what is the purpose of a screenign porgram
good treatment
reasonable test for it
acceptable test
cost effective
can be detected early
common conditions
sensitive/specific
wilsons criteria
screening tests in pregnancy
blood tests
scans - dating 12 weeks, normal scan 20 weeks - 11 conditions can be identified
screening for trisomies
first trimester - combined - serum HCG and PAPP-A
combined with nuchal translucency
crown rump length
second trimester - qaurdruple test - oestradiol, HCG, AFP, inhibin A
higher than 1 in 150 is HIGH RISK
chorionic villous sampling v amniocentesis
done earlier
amniocentesis - risk of infection, miscarriage
FISH for chromosome
20 week scan what conditions
anencephaly open spina bifida cleft lip diaphragmatic hernia gastroschisis exomphalos serious cardiac abnormalities bilateral renal agenesis lethal skeletal dysplasia Edwards' syndrome, or T18 Patau's syndrome, or T13
bilateral renal genesis
oligohydraminos
NIPE
newboen infant physical examination
hips
heart
eyes
testes
feel femoral -> coarction
midwife does it
NIPE smart portal
KPIs key performance indicators - are we delivering what we are supposed to
why we look at eyes in nIP
congenital cataracts
retinoblastoma prognosis POOR
immediate nucleation of eye with adverse chemo
tests for hips called
Barlow test
Ortolani test
clicks - US
FH and first degree relative - dislocated hip in newborn
pavlik harness
heart NIPE
murmurs and pulse
transposition
newborn blood spot
day 5
TFTs as thyroxine spikes on birth
newborn blood spot
day 5
TFTs as thyroxine spikes on birth
who might miss it
if their on neonatal units
families moving around a lot
metabolic disorders
Phenylketonuria - brain dev, MCADD, maple syrup, IVA, glutaric aciduria, homocystinuria
congenital hypothyroisism
CF - RIP
hearing tests
everyone gets it
otoacoustic emissions
AEBR
Ix if positive
cochlear implant
causes of preterm delivery
idiopathic intauterine stretch - multiples gestation - polyhydraminos - uterine abnormality endocrine maturation - premature onset of labour intrauterine bleeding - abruption - antepartum haemorrhage intrauterine infection - chorioamnioitis - bacterial vaginosis - preterm PROM fetus - IUGR - congenital malformations maternal medical conditins - pre-eclampsia, HTN chronic medical conditions UTIs cervical weakness
RFs or preterm delivery
- previous preterm infant, - a short inter-pregnancy interval (<6 months)
- maternal age (<20 or >35 years)
- obesity
- ethnicity (e.g. higher in Black mothers)
- multiple births
- maternal infection
- smoking
- substance misuse
- maternal psychological/social stress
define prematurity
classification
birth before 37 weeks
Under 28 weeks: extreme preterm
28 – 32 weeks: very preterm
32 – 37 weeks: moderate to late preterm
Management to hold baby in for longer
- > Prophylactic vaginal progesterone: putting a progesterone suppository in the vagina to discourage labour
- > Prophylactic cervical cerclage: putting a suture in the cervix to hold it closed
what can be done with preterm delivery to improve outcomes
- Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
- Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
- IV Magnesium sulphate: can be offered before 34 weeks gestation and helps protect the baby’s brain
- Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby
premauture babies problems in early life
Respiratory distress syndrome Hypothermia Hypoglycaemia Poor feeding Apnoea and bradycardia Neonatal jaundice Intraventricular haemorrhage IVH - small grade 1 upto 4 which are large - damage into brain tissue white matter damage periventricular leuko-malacia Retinopathy of prematurity Necrotising enterocolitis Immature immune system and infection
long term effects of premature babies
Chronic lung disease of prematurity (CLDP)
Learning and behavioural difficulties
Susceptibility to infections, particularly respiratory tract infections
Hearing and visual impairment
Cerebral palsy
examination of premature baby
dubowitz/balllard examination estimate neonatal maturity
external physical and neuromuscular features to determine a score. This is then used to give an estimate of a 2 week window of gestation.
Physical features assessed include skin, lanugo (thin, soft hairs), and eye, ear and genital formation.
Ix for premature babies
blood gas - metabolic state FBC - high risk of infection/anaemia U&Es blood culture CRP direct coombs test.direct antiglobuline test
chest xray if resp distressed
abdo xray - risk of necrotising enteroclitis
cranial US scan <32 weeks as they are at high risk of ntraventricular haemorrhage or ischaemic periventricular white matter damage
why do we administer steroids in premature babies
reduce the risk of death, intraventricular haemorrhage, respiratory distress
guidelines to start resuscitation
Less than 23 weeks then resuscitation should not be performed
Between 23 and 23+6 weeks then there may be a decision not to start resuscitation in the best interests of the baby, especially if parents have expressed this wish.
Between 24 and 24+6 weeks, resuscitation should be commenced unless the baby is thought to be severely compromised. Response to initial measures should be considered before the decision is made to commence intensive care.
After 25 weeks, it is appropriate to resuscitate and start intensive care.
what is physiological jaundice
mild yellowing of skin and sclera from 2 – 7 days of age. This usually resolves completely by 10 days
increased destruction of RBCs as the foetal HB is broken down. THis releases bilirubin into the blood and the immature liver is unable to conjugate and excrete it rapidly enough
causes of neonatal jaundice
increased production of bilirubin
Haemolytic disease of the newborn rhesus and ABO incompatibility Haemorrhage Intraventricular haemorrhage Cephalo-haematoma Polycythaemia Sepsis and disseminated intravascular coagulation G6PD deficiency
decreased clearance of bilirubin Prematurity Breast milk jaundice Neonatal cholestasis Extrahepatic biliary atresia hypothyroid and hypopituitary Gilbert syndrome
what is breast milk jaundice
components of breast milk inhibit the ability of the liver to process the bilirubin.
haemolytic disease of the newborn
cause of haemolysis (red blood cells breaking down) and jaundice in the neonate. It is caused by incompatibility between the rhesus antigens on the surface of the red blood cells of the mother and fetus.
what is sensitisation to rhesus D
When a woman that is rhesus D negative (does not have the rhesus D antigen) becomes pregnant, we have to consider the possibility that her child will be rhesus D positive (has the rhesus D antigen). It is likely at some point in the pregnancy the blood from the baby will find a way into her bloodstream. When this happens, the baby’s red blood cells display the rhesus D antigen. The mother’s immune system will recognise this rhesus D antigen as foreign and produce antibodies to the rhesus D antigen. The mother has then become sensitised to rhesus D antigens.
If that fetus is rhesus positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack their own red blood cells. This leads to haemolysis, causing anaemia and high bilirubin levels. This leads to a condition called haemolytic disease of the newborn.
what is prolonged jaundice
More than 14 days in full term babies
More than 21 days in premature babies
Structural – Biliary atresia / choledochal cyst / Alagille’s syndrome
Infective – CMV / EBV / Hep-B / Bacterial / Toxoplasmosis
Metabolic – Galactosaemia / Alpha-1-antitrypsin deficiency / Storage disease
Genetic – CF / Trisomy 21 / Trisomy 18
Neoplastic – Hepatoblastoma / Neuroblastoma
Toxic – Drug induced
Endocrine – Hypothyroidism / Panhypopituitarism
Vascular – Budd-Chiari / Congestive heart failure
Ix for jaundice in neonates
- FBC +Blood film for polycythaemia or anaemia
- Total serum bilirubin/LFTs
- Blood type testing of mother and baby for ABO or rhesus incompatibility
- coagulation study - deranged indicates poor liver function
- Paternal blood group and rhesus status
- Peripheral blood smear - misshapen blood cells could indicate RBC disorder
- Reticulocyte count - for presence of haemolysis
- Direct Coombs Test (direct antiglobulin test) for haemolysis
- Thyroid function, particularly for hypothyroid
- Blood and urine cultures if infection is suspected.
- G6PD levels ->deficiency
- Galactosaemia screen
- TORCH fro infection
Mx of jaundiced neonates
observe for 24 hours
total bilirubin levels are monitored and plotted on treatment threshold charts. These charts are specific for the gestational age of the baby at birth. The age of the baby is plotted on the x-axis and the total bilirubin level on the y-axis. If the total bilirubin reaches the threshold on the chart, they need to be commenced on treatment to lower their bilirubin level.
- > Phototherapy is usually adequate to correct neonatal jaundice. Extremely high levels may require an exchange
- > transfusion. Exchange transfusions involve removing blood from the neonate and replacing it with donor blood.
how does phototherapy work
unconjugated bilirubin into isomers that can be excreted in the bile and urine without requiring conjugation in the liver.
Once phototherapy is complete, a rebound bilirubin should be measured 12 – 18 hours after stopping to ensure the levels do not rise about the treatment threshold again.
considerations
- distance of light of baby
- eye protection
- remove clothes off baby except nappy
- temperature
- bilirubin levels
what is kernicterus
type of brain damage caused by excessive bilirubin levels. It is the main reason we treat neonatal jaundice to keep bilirubin levels below certain thresholds.
Bilirubin can cross the blood-brain barrier. Excessive bilirubin causes direct damage to the central nervous system. Kernicterus presents with a less responsive, floppy, drowsy baby with poor feeding. The damage to the nervous system is permeant, causing cerebral palsy, learning disability and deafness
