Neonatology Flashcards
What is hypoxic ischaemic encephalopathy ?
-> Prolonged or severe hypoxia during birth leading to ischaemic brain damage.
-> HIE can lead to permanent damage to the brain, causing cerebral palsy.
Give 4 causes of HIE
ANYTHING CAUSING ASPHYXIA
-> Maternal shock
-> Intrapartum haemorrhage
-> Prolapsed cord : causing compression of the cord during birth
-> Nuchal cord : cord is wrapped around neck of the baby
What is used to grade the severity of HIE?
-Sarnat staging
What are the features of mild HIE (3)
-Poor feeding, generally irritable and hyper-alert
-Resolves within 24 hrs
-Normal prognosis
What are the features of moderate HIE (4)
-Poor feeding, lethargic hypotonic and seizures
-Can take weeks to resolve
-Up to 40% develop cerebral palsy
What are the features of severe HIE (4)
-Reduced consciousness, apnoeas, flaccid and reduced or absent reflexes
-Up to 50% mortality
-Up to 90% develop cerebral palsy
What can be done to reduce risk of severe damage from HIE
-> Therapeutic Hypothermia
-> Carefully cooling a baby in ICU to between 33 and 34 degrees, measruing with a rectal probe
-> Continued for 72 hrs, after which the baby is warmed over 6 hrs
-> Done to reduce inflammation and neuron loss after acute hypoxic injury
What 5 things are scored in apgar scores
-HR
-Resp effort
-Muscle tone
-Reflex irritability
-Colour
0-3 = very low
4-6 = moderate low
7-10 = baby is ok
Define prematurity
-Born before 37 weeks
<24 wks - extreme preterm
28-32 wks - very preterm
32-37 wks - moderate to later preterm
What is associated with prematurity ?
-Social deprivation
-Smoking
-Alochol
-Drugs
-Overweight or underweight mother
-Maternal co-morbidities
-Twins
-Personal or family history of prematurity
What 2 thing can be done to try and delay birth in evidence of prematurity ?
-Prophylactic vaginal progesterone
-Prophylactic cervical cerclage -> suture in cervix to hold shut
If preterm labour is confirmed, what can done to improve outcomes?
-Nifedipine to suppresses labour
-Maternal corticosteroids before 35 wks
-IV magnesium sulphate before 34 wks to protect babys brain
-Delayed cord clamping or cord milking to increase circulating blood volume and Hb in the baby
Give issues in early life following premature birth (10)
-Resp distress syndrome
-Hypothermia
-Hypoglycaemia
-Poor feeding
-Apnoea and bradycardia
-Neonatal jaundice
-Intraventricular haemorrhage
-Retinopathy of prematurity
-Necrotising enterocolitis
-Immature immune system and infection
Give 5 long term effects of prematurity
-Chronic lung disease of prematurity
-Learning and behavioural difficulties
-Susceptibility to infections
-Hearing and visual impairment
-Cerebral palsy
Why does respiratory distress syndrome occur in premature neonates?
-<32 wks there is inadequate surfactant leading to high surface tension within alveoli
-This leads to lung collapse as it is more difficult for alveoli and lungs to expand
-There is inadequate gaseous exchange, causing hypoxia, hypercapnia and resp distress
How is respiratory distress managed ?M (4)
-Intubation and ventilation
-Endotracheal surfactant
-CPAP
-Oxygen
What can be given to mothers with suspected or confirmed preterm labour to reduced incidence and severity of respiratory distress syndrome in the baby
-Antenatal steroids (e.g. dexamethasone) to increase surfactant production
Give 6 short term complications of respiratory distress syndrome
-Pneumothorax
-Infection
-Apnoea
-Intraventricular haemorrhage
-Pulmonary haemorrhage
-Necrotising enterocolitis
Give 3 long term complications of respiratory distress syndrome
-Chronic lung disease of prematurity
-Retinopathy of prematurity
-Neurological, hearing and visual impairment
What is necrotising enterocolitis ?
-Disorder affecting premature neonates where part of the bowel becomes necrotic
-Death of bowel tissue can lead to perforation -> peritonitis -> shock
Give 5 risk factors for necrotising enterocolitis
-Very low birth weight or very premature
-Formula feeds
-Respiratory distress and assisted ventilation
-Sepsis
-Patient ductus arteriosus and other congenital heart disease
How can necrotising enterocolitis present ?
-Intolerance to feeds
-Vomiting, usually green bile
-Generally unwell
-Distended, tender abdomen
-Absent bowel sounds
-Blood in stool
What is the investigation of choice for diagnosing necrotising enterocolitis ?
-Abdo X-ray
-Done front on in supine position
What will an abdo x-ray show in necrotising enterocolitis ?
-Dilated loops of bowel
-Bowel wall oedema
-Gas in the bowel wall
What will be seen on bloods in necrotising enterocolitis ?
-FBC : thrombocytopenia and neutropenia
-CRP : raised
-Capillary blood gas -> metabolic acidosis
-Blood culture for sepsis
How is necrotising enterocolitis managed ?
-Total parenteral nutrition (TPN) and antibiotics to stabilise
-Nasogastric tube to drain fluid and gas from stomach and intestines
- Laparotomy if perforation
Give 8 complications of necrotising enterocolitis
-Perforation and peritonitis
-Sepsis
-Death
-Strictures
-Abscess formation
-Recurrence
-Long term stoma
-Short bowel syndrome after surgery
What are breastfed babies more likely to develop jaundice ?
-Components of breast milk inhibit the ability of the liver to process bilirubin
-Breastfed babies are more likely to become dehydrated if not feeding adequately.
-Inadequate breastfeeding = slow passage of stools, increasing absorption of bilirubin in the intestines
Explain haemolytic disease of the newborn
-Mum = rhesus D negative
-Baby = rhesus D positive
-Mother recognises the rhesus antigen as foreign and produces antibodies
-Second baby = anti-D antibodies cross the placenta
-If the second baby is rhesus D positive = haemolysis = anaemia and high bilirubin levels
Give the 6 steps of neonatal resus
- Warm the baby by getting them dry
- Caclulat APGAR score
Give the 5 steps of neonatal resus
- Warm the baby by getting them dry
- Calculate APGAR score
- Stimulate breathing : head in neutral position, dry vigourously.
- Inflation breathes : 2 cycles of 5 breathes lasting 3 seconds each.If no response, 30 secs of ventilation breathes
- Chest compressions if HR remains below 60 bpm -> 3:1 ratio with ventilation breaths
What 5 organisms commonly cause neonatal jaundice ?
-GBS -> common
-E.coli
-Listeria
-Klebsiella
-Staph aureus
What are the clinical features of neonatal sepsis (10)
-fever
-Reduced tone and activity
-Poor feeding
-Resp distress or apnoea
-Vomiting
-Tachy or bradycardia
-Hypoxia
-Jaundice within 24 hrs
-Seizures
-Hypoglycaemia
Give 6 RF for neonatal sepsis
-Vaginal GBS
-GBS in previous baby
-Maternal sepsis
-Prematurity (<37 wks)
-Early rupture of membrane
-Prolonged rupture of membranes (PROM)
What are the two 1st line medications for neonatal sepsis ?
- IV Benzylpenicillin and gentamycin
What are the 5 increased bilirubin production causes of jaundice in neonates
- Haemolytic disease of newborn
- ABO incompatibility
- Polycythaemia
- G6PD deficiency
- Sepsis and DIC
what is a common cause of jaundice in the 1st 24 hrs of life
Neonatal sepsis
what are 6 decreased bilirubin clearance causes of neonatal jaundice
- Prematurity
- Breast milk jaundice
- Neonatal cholestasis
- Gilberts
- Biliary atresia
- Endocrine disorders (hypothyroid, hypopituitary)
how is neonatal jaundice managed
-Phototherapy -> converts unconjugated bilirubin to isomers which can be excreted in bile and urine
what is physiological jaundice
-Neonate = high conc of fragile RBCs & less developed liver function
-These RBCs break down rapidly
-There is a normal rise in bilirubin shortly after birth with mild yellowing of sclera
What is kernicterus ?
-Brain damage due to excess bilirubin in neonate as bilirubin can cross BBB
-Can cause cerebral palsy, learning difficulties and deafness
-Traumatic, prolonged or instrumental delivery (e.g.ventouse)
-Soft, puffy occipital swelling that crosses suture lines
-No treatment needed, will resolve in a few days
Caput seccedaneum : fluid collecting on the scalp OUTSIDE the periosteum and caused by pressure
-Traumatic, prolonged, instrumental delivery.
-Lump on the skull, that DOES NOT CROSS suture lines
-Discolouration of the skin in the affected area
-Cephalohaematoma : collection of blood between skull and periosteum. As it is BELOW the periosteum it does not cross suture lines
Normal vaginal delivery
Convulsion within 48 hrs
No head trauma or swellings
Intra-ventricular haemorrhage -> in premature neonates can occur spontaneously
what causes an erb’s palsy
- Injury to C5/C6 during birth
- Is associated with shoulder dystocia, traumatic or instrumental delivery and large birth weight
How does Erb’s palsy present
- Internally rotated shoulder
- Elbow extended
- Flexed wrist facing backwards (pronated)
- Lack of movement in affected arm
‘waiters tip”
what is gastroschisis and its managed
- Congenital defect in the anterior abdo wall LATERAL to the umbilical cord.
- Management : vaginal delivery, take newborn to theatre within 4 hrs
what is exomphalos (omphalocoele) and its management
- Abdominal contents protrude through abdo wall but are covered by amniotic sac
- C section to protect the sac from rupture with staged repair
Oesophageal atresia : associations, presentation
- Associations : tracheo-oesophageal fistula, polyhydramnios
- Presents : chocking and cyanotic spells following aspiration
RF for meconium aspiration (5)
- Post term delivery
- Maternal HTN
- Pre eclmapsia
- Chorioamnionitis
- Smoking or substance use
How is neonatal hypoglycaemia managed if asymptomatic
- Encourage normal feeding
- Monitor blood glucose
How is neonatal hypoglycaemia managed if symptomatic / very low blood glucose
- Admit
- IV 10% dextrose
Most common causes of neonatal sepsis
GBS
E.coli
Give 4 RF for GBS infection
- Prematurity
- Prolonged rupture of membranes
- Previous sibling with GBS
- Maternal pyrexia (e.g. secondary to chorioamnionitis)
Where does HSV typically affected in encephalitis
Temporal lobes
What can increase the risk of cleft lip and palate
- Maternal antiepileptic use
