Neonatology Flashcards
What is the neonatal period
4 weeks after due date
Commonest congenital heart lesions in the neonatal period
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%)
Which conditions present with cyanosis
Right-to-left shunts and mixing..
Tetralogy of Fallot
TPA
AVSD
Acyanotic lesions
Left-to-right shunts and outflow obstruction (if not severe)
VSD
ASD
PDA
Pulmonary stenosis
Aortic stenosis
Signs of small VSDs
Asymptomatic
Loud pansystolic murmur at LLSE
Quite pulmonary 2nd sound
Echo demonstrates percise anatomy of the defect
Signs of Large VSDs
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
Investigation results in large VSDs
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
Presentation of PDA
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
Physical signs of aortic stenosis
Small volume - slow rising pulse
Carotid thrill
Ejection systolic murmur maximal at the URSE radiating to the neck
Delayed and sort aortic 2nd sound
Investigation results in aortic stenosis
CXR:
normal or prominent LV with post-stenotic dilation of ascending aorta
ECG - LV hypertrophy
Pulmonary stenosis physical signs
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
investigation results in pulmonary stenosis
Normal or post-stenotic dilation of pulmonaryy artery
ECG - RV hypertrophy (upright T wave in V1)
Symptoms of ASD
None
Recurrent chest infections/wheeze
Arrhythmias - 4th decade onward
Physical signs of ASD
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
Investigation results in ASD
CXR - cardiomegaly, enlarged pulmonary arteries and increased pulmonary vascular markings
ECG - partial RBBB
Echo - will show anatomy - mainstay
Presentation of Tetralogy of Fallot
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
Signs of tetralogy of fallot
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
Investigation results in tetralogy of Fallot
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
Clinical features of coarctation of the aorta
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
Investigation findings with coarctation of the aorta
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
TPA clinical presentaitn
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)
Signs of TPA
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
Investigation results in TPA
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
What is Atrioventricular septal defect
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
Features of AVSD
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
