Neonatology Flashcards
early onset neonatal sepsis definition
sepsis occurring within the first 48-72 hours of life
prevalence EONS
0.9/1000 live births and 9/1000 admissions in uk…rare
mortality rate 16%
most likely cause of severe neonatal infection
group B strep
others - e.coli, coagulase neg strep, haem influenzae and listeria monocytogenes
EONS pathophysiology
ascending infection in the mother with chorioamnionitis, perinatally via direct contact in birth canal and haematogenous spread
clinical features - early and late in EONS
early - resp distress, pneumonia, sepsis
later - sepsis and/or meningitis
chorioamnionitis in mothers prevention
can give intrapartum abx
risk factors for infection EONS
Invasive group B streptococcal infection in a previous baby
Maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy
Prelabour rupture of membranes
Preterm birth following spontaneous labour (before 37 weeks’ gestation)
Suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth
Intrapartum fever higher than 38°C, or confirmed or suspected chorioamnionitis
red flags for EONS
parental abx given to woman at any point during labour or in 24 hr period before and after birth
infection in another baby in case of multiple pregnacny
red flags clinical features EONS
resp distress starting more than 4 hours after birth
seizures
need for mechanical ventilation in a term baby
signs of shock
EONS ddx
transient tachypnoea of newborn
ARDS
meconium aspiration
EONS investigations
FBC
CRP
blood cultures
LP
EONS management
IV benzylpenicillin with gentamicin for 7-10 days if blood cultures positive or 14 days if CSF also positive
consider stopping at 36 hrs if think infection not present
prognosis EONS
mortality 2-4%
higher if low birth weight or pre term
prevalence neonatal jaundice
60% of term infants and 80% of preterm infants
unconjugated - can be physiology or pathological or conjugated which is always pathological
physiological jaundice
increased red cell breakdown - in utero fetus has high conc of Hb …broken down
immature liver - not process high billirubin
resolves by day 10
can progress to pathological if baby premature or increased cell breakdown from bruising
pathological jaundice
haemolytic disease - of newborn, ABO incompatibility, G6PD deficiency, spherocytosis
bilirubin above phototherapy threshold - likely dehhydrated aor due to bruising etc
unwell neonate - infection
prolonged jaundice - >14 days in infants, >21 days in preterm
prolonged jaundice causes
Infection
Metabolic: Hypothyroid/pituitarism, galactosaemia
Breast milk jaundice: well baby, resolves between 1.5-4 months
GI: biliary atresia, choledhocal cyst
risk factors for pathological jaundice
Prematurity, low birth weight, small for dates
Previous sibling required phototherapy
Exclusively breast fed
Jaundice <24 hours
Infant of diabetic mother
clinical presentation jaundice
colour of baby
drowsy - not waking for feeds
neuro - altered muscle tone, seizures
other - signs of infection, poor UO, abdo mass, stool remains black/not chnaging colour
jaundice investigations billirubin
Transcutaneous bilirubinometer (TCB) can be used in >35/40 gestation and >24 hours old for first measurement. TCB can be used for all subsequent measurements, providing the level remains <250 µmol/L and the child has not required treatment
Serum bilirubin to be measured if <35/40 gestation, <24 hours old or TCB >250 µmol/L
jaundice investigations other
serum billirubin
blood group and DCT
FBC
UE
infection screen
glucose 6 P dehydrogenase
LFT
TFT
management billirubin
phototherapy - look at charts
ex[ressed materal milk
consider NG and IV fluids if feeding poor
exchange transfusion - with donated blood or plasma via umbilical artery or vein
IV immunoglobulin
complications neonatal jaundice
Kernicterus, billirubin-induced brain dysfunction, can result from neonatal jaundice. Bilirubin is neurotoxic and at high levels can accumulate in the CNS gray matter causing irreversible neurological damage.
meconium aspiration syndrome definition
spectrum of disorders…various degrees of resp distress due to the aspiration of meconium stained amniotic fluid
mostly during birth, can occur antenatally
what is meconium
dark green, sticky and lumpy faecal material produced during pregnancy. usually released from bowels after birth but sometimes can pass in utero leading to MSAF
MSAF pathophysiology
the after effect of in utero peristalysis
usually is the result of foetal hypoxic stress or vagal stimulation due to cord compression…also causes foetus to gasp
once aspirated - stimulates release of vasoactive and cytokine substances…active inflammatory pathway and inhibits effect of surfactant
factors contributing to resp distress in MASF
partial/total airway obstruction - as meconium thick…atelectasis. Pulmonary pressure increases, right to left shunt through patent ductus arteriosus/foramen ovale…V/Q mismatch
- foetal hypoxia - V/Q mismatch, increase pulmonary vascular pressures, mechanical obstruction
- pulmonary inflammation - due to pro-inflammatory cytokines
- infection - meconium good medium for organisms, inflammation process predisposes to
- surfactant inactivation - increases surface tension of alveoli..reduced gas exchange
- persistent pulmonary HTN - remodeling of pulmonary vascular bed in response to hypoxia
major cause of morbidity and mortality in MSAF
PPHN
risk factors for MSAF
Gestational Age > 42 weeks
Foetal distress (tachycardia / bradycardia)
Intrapartum hypoxia secondary to placental insufficiency
Thick meconium particles
Apgar Score <7
Chorioamnionitis +/- Prolonged pre-rupture
Oligohydramnios
In utero growth restriction (IUGR)
Maternal hypertension, diabetes, pre-eclampsia or eclampsia, smoking and drug abuse
examination MSAF
Tachypnoea – a respiratory rate of >60 breaths per minute
Tachycardia – a heart rate of >160 beats per minute
Cyanosis – this requires immediate management
Grunting
Nasal flaring
Recessions – intercostal, supraclavicular, tracheal tug
Hypotension – systolic blood pressure of <70 mmHg
MSAF investigations
CXR -increased lung volumes
asymmetrical patchy pulmonary opacities
pleural effusions
pneumothorax or pneumomediastinum
multifoc
infection markers
dual pulse oximetry
ECHO
CRANIAL USS consolidation
ddx MSAF
transient tachypnoea of newborn
surfactant deficiency
persistent pulmonary HTN
management MSAF
observation - 02 sats
infant warmer
bloods
IV fluids
O2 via nasal cannula (92-97%)
CPAP or intubated
abx - if infection
bolus of surfactant or lung lavage with surfactant
inhaled NO
corticosteroids
complications MSAF
air leak - pnumonothorax or pneumomediastinum
PPHN
cerebral palsy
chronic lung disease
necrotising enterocolitis epidemiology
1-3/1000 births
reduced 6 fold in breastfed infants
pathophysiology NEC
likely due to innate immune response to microbiota or premature infant’s gut
risk factors NEC
Prematurity or very low birth weight (VLBW)
Formula feeding
Intrauterine growth restriction (IUGR)
Polycythaemia
Exchange transfusion
Hypoxia
clinical features NEC
feeding intolerance
vomiting - bile or blood stained
abdo distention and haematochezia
abdo tenderness
abdo oedema
erythema
palpable bowel loobs
systemic features - apnoea, lethargy, bradycardia, decreased peripheral perfusion
investigations NEC
plain abdo x ray - distended bowel loops, thickened bowel wall, intramural gas, pneumoperitoneum
FBC, UE, blood gas, blood culture
staging NEC
bell scoring system
1 to 3
suspected, definite, advanced
clinical features and radiological
prophylactic management NEC
antenatal steroids if premature delivery anticipated
breastfeeding
probiotics
medical management MEC
if stage 1 or 2
Withhold oral feeds for 10-14 days and replace with parenteral nutrition.
IV antibiotics for 10-14 days based on local protocols.
Systemic support in the form of ventilatory support, fluid resuscitation, inotropic support, correction of acid-base balance coagulopathy and/or thrombocytopenia.1
indications for NEC
Intestinal perforation
GI obstruction secondary to stricture formation
Deterioration despite medical management1
surgical management NEC
intestinal resection with stoma formation
complications NEC
intestinal perforation
sepsis
death
long term - strictures, short bowel syndrome, neu
preterm birth definition
before 37 completed week’s gestation
Extreme preterm: before 28 weeks
Very preterm: 28 to 32 weeks
Moderate to late preterm: 32 to 37 weeks
number 1 cause of neonatal death globally
prematurity
associations for neonatal death in premature delivery
life threatening conditions - pre eclampsia, renal disease
due to premature rupture of membranes
emergency event - placental abruption
40% have no identifiable cause
epidemiology pre term
15 million babies each year
60% in africa and south asia as well as high income countries
risk factors for premature delivery
Previous preterm delivery
Multiple pregnancy
Smoking and illicit drug use in pregnancy
Being under or overweight in pregnancy
Early Pregnancy (within 6 months of previous pregnancy)
Problems involving cervix, uterus or placenta, including infection
Certain chronic conditions such as diabetes and hypertension
Physical injury/trauma
hx preterm labour
estimated due date
last menstrual period
assessment of gestational age
examination preterm infant
dubowitz/ballard exam for gestational age - assess neonatal maturity - external physical and neuomuscular features to avoid hypothermia
physical features to assess - skin, lanugo, eye, ear and genital formation, posture and arm recoil
investigations preterm infant
blood gas
FBC
U+E
blood culture
CRP
blood group and direct coombs test/direct antiglobulin test
CXR
abdo X ray
cranial USS
central venous/arterial access in preterm infant
umbilical vein, atery
initial management pre term infant
if planned - tertiary level neonatal unit
antenatal steroids
magnesium sulphate - neuroprotective
resuscitation guidlines pre term
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
After 25 weeks, it is appropriate to resuscitate and start intensive care.
resp system pre term
resp distress syndrome, surfactant deficient, CLD
…exogenous surfactant, intubation, CPAP, oxygen
CVS pre term
hypotension, PDA
inotrope infusion, fluid, ibuprofen or indomethacin, ligation of PDA
neuro pre term infant
intraventricular haemorrhage, seizures, cerebral palsy…surveillance with cranial USS, head circumferences, antiepileptic drugs, referral, follow up, awareness of stimulation
GI pre term
feeding intolerance, NEC,..TPN, NG, maternal and donor expressed breast milk, abx
renal premature
immature function
monitor fluid and electrolyte, consider catheter
metabolic premature
jaundice, hyper or hypoglycaemia, inborn errors of metabolism…phototherapy, exchange transfusion, insulin infection, glucose via central IV access
infection premature
sepsis, infection…sepsis screen, IV abx
skin premature
insensible losses and increased risk of infection…nursing in warm, humid intubator, ANNT
thermoregulation premature
immature…nursing in warm humid incubator, cot warmer, awareness of exposure
eyes premature
retinopathy of prematurity…avoid excess o2 exposure, screening, laser tx
prognosis prematurit
survival rare <23 weeks
by 26 weeks, 3/4 survive
90% at 27 weeks
neurodevelopmental prognosis premature
gross motor delay
fine morot
speech and language
learning and behaviour
family support prematurity
eriods of kangaroo care/skin-to-skin should be encouraged. There are often local support groups available for parents and charities such as Bliss
ethics prematurity
complex…when to withdraw intensive care
