Neonatology

Question 1

What is the neonatal period

Answer 1

4 weeks after due date

Question 2

Commonest congenital heart lesions in the neonatal period

Answer 2

Left-to-right shuft
30% VSD
12% PDA
7% ASD

Right-to-left shunts (blue):
Tetralogy of Fallot (5%)
Transposition of greater arteries (5%)

mixing (breathless and blue):
atrioventricular septal defect

Outflow obstruction in a well child:
(asymptomatic with murmur)
Pulmonary stenosis (7%)
Aortic stenosis (5%)

Question 3

Which conditions present with cyanosis

Answer 3

Right-to-left shunts and mixing..

Tetralogy of Fallot
TPA
AVSD

Question 4

Acyanotic lesions

Answer 4

Left-to-right shunts and outflow obstruction (if not severe)

VSD
ASD
PDA

Pulmonary stenosis
Aortic stenosis

Question 5

Signs of small VSDs

Answer 5

Asymptomatic

Loud pansystolic murmur at LLSE

Quite pulmonary 2nd sound

Echo demonstrates percise anatomy of the defect

Question 6

Signs of Large VSDs

Answer 6

Heart failure with breathlessness and FTT after 1 week

Recurrent chest infections

Tacyhpnoea
Tachycardia
Enlarged liver from HF
Active precordium
Soft pansystolic murmur or no murmur
Apical mid-diastolic murmur - due to increased flow across mitral valve

Question 7

Investigation results in large VSDs

Answer 7

CXR - cardiomegaly, enlarged pulmonary arteries, increased pulmonary vascular markings, pulmonary oedema

ECG:
biventricular hypertrophy 2 months

Echo - shows the anatomy of the defect, haemodynamic effects and pulmonary HTN

Question 8

Presentation of PDA

Answer 8

Murmur beneath left clavicle - continues into diastole, because the pressure in the pulmonary artery is lower than that in the aorta throughout the cardiac cycle

Collapsing or bounding pulse

Usually asymptomatic..
If duct is large, there is increased pulmonary blood flow with heart failure and pulmonaryy HTN

Duct can be seen on echo

Question 9

Physical signs of aortic stenosis

Answer 9

Small volume - slow rising pulse
Carotid thrill
Ejection systolic murmur maximal at the URSE radiating to the neck

Delayed and sort aortic 2nd sound

Question 10

Investigation results in aortic stenosis

Answer 10

CXR:
normal or prominent LV with post-stenotic dilation of ascending aorta

ECG - LV hypertrophy

Question 11

Pulmonary stenosis physical signs

Answer 11

Ejection systolic murmur at the ULSE - thrill may be present

Ejection click best heard at the ULSE

When severe, there is a prominent RV impulse - heave

Question 12

investigation results in pulmonary stenosis

Answer 12

Normal or post-stenotic dilation of pulmonaryy artery

ECG - RV hypertrophy (upright T wave in V1)

Question 13

Symptoms of ASD

Answer 13

None
Recurrent chest infections/wheeze

Arrhythmias - 4th decade onward

Question 14

Physical signs of ASD

Answer 14

Ejecton systolic murmur at ULSE, due to increased flow across pulmonary valve

Widely split 2nd heart sound - because right ventricular stroke volume is equal in inspiration and expiration

Question 15

Investigation results in ASD

Answer 15

CXR - cardiomegaly, enlarged pulmonary arteries and increased pulmonary vascular markings

ECG - partial RBBB

Echo - will show anatomy - mainstay

Question 16

Presentation of Tetralogy of Fallot

Answer 16

Severe cyanosis
Hypercyanotic spells
Rare in developed countries

Hypercyanotic spells may lead t MI, CVA or death if left untreated
- there is a rapid increase in cyanosis, associated with irritability or inconsolable crying due to severe hypoxia, breathlessness and pallor

Question 17

Signs of tetralogy of fallot

Answer 17

Clubbing of the finger and toes will develop in older children

Loud, harsh ejection systolic murmur at te LSE from day 1
With increasing right ventricular outflow tract obstruciton, which is predominantly muscular and below the pulmonary valve
The murmur will shortn and cyanosis will increase

Question 18

Investigation results in tetralogy of Fallot

Answer 18

CXR - relatively small heart with a “boot-shaped” apex due to RV hypertrophy

Decreased pulmonary vascular markings reflecting reduced pulmonary flow

ECG - RV hypertrophy when older

Echo - will demonstrate cardinal features, but cardiac catheterisaton may be needed to show the detailed anatomyy of the coronary arteries

Question 19

Clinical features of coarctation of the aorta

Answer 19

Asymptomatic
Systemic HTN in the right arm
Ejection systolic murmur at USE
Collaterals heard with continuous murmur at back

Radio-femorall delay - due to blood bypassing the obstruction via collateral vessels in the chest wall and hence the pulse in the legs is delayed

Question 20

Investigation findings with coarctation of the aorta

Answer 20

CXXR - rib-notching due to development of large collateral intercostal arteries running under the ribs posteriorly to bypass the obstruction
- 3 sign (visible notch in the descending aorta at the site of coarctation)

ECG - LV hypertrophy

Question 21

TPA clinical presentaitn

Answer 21

Cyanosis
May be profound and life-threatening and usuallyy on day 2 of life when the DA closes leading to a marked reduction in the mixing of saturated and desaturated blood

Cyanosis will be less severe and presentation delayyed if there is more mixing of blood (eg. ASD)

Question 22

Signs of TPA

Answer 22

Cyanosis - ALWAYS
2nd heart sound is often loud and single

Usually no murmur - may be a systolic murmur from increased flow or stenosis within the LV outflow tract

Question 23

Investigation results in TPA

Answer 23

CXR - narrow upper mediastinum. “egg-on side” appearance of the cardiac shadow
-due to anteroposterior relationship of the great vessels and hyypertrophied right ventricle

Increased pulmonaryy vascular markings due to increased pulmonary blood flow

Echo - demonstrates the abnormal arterial connections

Question 24

What is Atrioventricular septal defect

Answer 24

In the middle of the heart, there is a single five leaflet valve between the atria and ventricle.
It stretches across the entire atrioventricular junction and tends to leak. Pulmonary HTN

Question 25

Features of AVSD

Answer 25

Presentation on antenatal US screening

Cyanosis at birth or heart failure at 2-3 weeks
no murmur heard (lesion may be detected on routine echo in Down syndrome)

Always superior ais on ECG