Neonatology Flashcards
What are causes of polyhydramnios?
(Severe)
- Fetal anomalies - Decreased swallowing (GI obstruction) or increased amniotic fluid production (renal hyperperfusion)
- Aneuploidies (T21, T18)
(Milder)
- Maternal diabetes
- Multiple gestation
- Idiopathic - Fetal anaemia, Bartter syndrome, infection (TORCH), neuromuscular disorders
What are the parameters for AFI?
AFI 8-18 = Normal
AFI <5-6 = Oligohydramnios
AFI >24-25 = Polyhydramnios
What are the energy requirements of infants?
Infants with chronic illness = 150 kcal/kg/day
Premature infant = 120 kcal/kg/day (enterally fed)
= 80-100 kcal/kg/day (parenterally fed)
Term neonate = 100-120 kcal/kg/day
1-12 months = 90-100 kcal/kg/day
1-6 years = 75-100 kcal/kg/day
How much protein do infants require?
Premature = 2.5-3g/kg/day
Infants (0-1 years) = 2.5g/kg/day
Children (2-13 years) = 1.5-2g/kg/day
Adolescents/adult =
What are the insensible fluid losses in a neonate?
<750g = 4ml/kg/hr 750-1000g = 3ml/kg/hr 1000-1500g = 2ml/kg/hr >1500g = 1ml/kg/hr
What are causes of increased insensible fluid losses?
Increased RR, surgical malformations, increased ambient temperature, increased motor activity
What are the causes of decreased insensible fluid losses?
Use of incubators, humidification of inspired gas, increased ambient humidity, thin plastic barriers.
What is the most common aneuploidal cause of non-immune fetal hydrops?
Turner syndrome
What is the most common group cause of non-immune hydrops fetalis?
Cardiovascular - Accounts for around 40% of cases
- Structural
- Arrhythmias
- Vascular
What is the most common cause of non-immune fetal hydrops in Southeast Asians?
Alpha-thalassaemia.
Fetal hydrops develops early mid-trimester.
AR condition, with mutation/deletion of haemoglobin alpha gene. Gamma chains accumulate to form haemoglobin Barts (which bind oxygen but cannot release). Can see using high-performance liquid chromatography or electrophoresis.
What is the most common intrathoracic mass cause of non-immune hydrops fetalis?
Congenital pulmonary malformation
Bronchopulmonary sequestration
What are the broad categorical causes of non-immune hydrops fetalis?
Cardiovascular (40%) - Structural, arrhythmias, vascular
Anaemia (10-27%) - Alpha thalassaemia (SEA)
Aneuploidy (7-16%) - Turner
Syndromes (5-10%) - e.g. Noonan
Infection (5-10%) - Parvovirus B19
Thoracic and lymphatic abnormalities (10%)
Twin gestation
Genitourinary and gastrointestinal abnormalities
Inborn errors of metabolism - e.g. Lysosomal storage
Skeletal dysplasias
Where do neonates lose their insensible fluids?
2/3 skin
1/3 respiratory tract
What is the difference in body water composition in neonates compared with adults?
Neonates = 70% water Adult = 60% water
Preterm neonates have proportionally more water than term (e.g. 90% at 23/40)
What is the definition of ‘extremely low birth weight’ and ‘extremely preterm’?
Extremely preterm = GA <28 weeks
Very preterm = GA 28-31+6
Moderate preterm = GA 32-33+6
Late preterm = GA 34-36+6
Extremely low birth weight = <1000g
Very low birth weight = <1500g
Low birth weight = <2500g
What conditions are associated with preterm births?
Bronchopulmonary dysplasia
Perinatal infections (NEC, sepsis, meningitis)
ROP
IVH
Poor growth
Congenital anomalies
Surgical procedures during birth hospitalisation
What is the commonest cause of oligohydramnios?
Rupture of membranes
Usually occurs in third trimester
- First trimester - Aetiology often unclear, poor prognosis.
- Second trimester -Related to renal/urinary disorders. Also maternal and placental factors (PPROM, placental abruption, FGR)
- Third trimester - PPROM, uteroplacental insufficiency
What maternal drugs affected metabolism of vitamin K in the neonate?
- Warfarin
- Anti-tuberculosis drugs
e. g. rifampin, isoniazid) - Antiseizure drugs
e. g. phenytoin, barbiturates, carbamazepine
What are the causes of DIC in the newborn?
Hypoxia Hypotension Asphyxia Sepsis (bacterial or viral) NEC Neonatal cold injury Neonatal neoplasm Hepatic disease Death of twin in utero
What are the haematological markers of DIC?
Increased aPTT and PT ++ Decreased platelets Microangiopathic haemolytic anaemia Decreased fibrinogen Increased fibrin degradation products
Which maternal drugs cause thrombocytopenia in the newborn?
Quinine, quinidine, thiazide diuretics, sulfonamides
Apart from maternal drugs and syndromic causes, what are non-syndromic causes of thrombocytopenia in a well neonate?
- Transient ISOIMMMUNE thrombocytopenia
Antiplatelet antibodies produced by HPLA-1 negative mother to paternal platelet antigen (HPA-1a and HPA-5b). Crosses placenta to baby. - Transient NEONATAL thrombocytopenia
Transfer of maternal IgG antibodies across placenta directed against all palatelet antigens (BOTH mother and baby have decreased platelets)
What is the leading cause of non-hereditary sensorineural hearing loss?
Congenital CMV infection
What are the symptoms of congenital CMV infection?
- Sensorineural hearing loss (33-50%)
Can be delayed and bilateral. - Chorioretinitis
Other ocular: Retinal scars, optic atrophy, central vision loss) - Somatic menifestations
(Jaundice, petechiae, microcephaly) - Ascites, myocarditis, cardiomyopathy, ventricular trebeculations
(Can present as fulminant disease with viral-associated haemophagocytic syndrome or severe end-organ disease.
What is the most common ocular abnormality in congenital CMV?
Chorioretinitis
What is the transmission rate to infant in primary vs. secondary congenital CMV?
Primary - 50% risk transmission; symptomatic in 10% cases, and carry 90% risk of sequelae.
Non-primary - <1% risk transmission; >99% will have asymptomatic congenital CMV (of these, 5% SNHL, 2% chorioretinitis)
What are in utero ultrasound findings suggestive of CMV disease?
Periventricular calcifications Ventriculomegaly Migrational abnormalities of brain Microcephaly FGR Ascites/pleural effusion
Apart from SNLH, choriorenitis and microcephaly, what are other common signs seen in congenital CMV?
Petechiae Jaundice at birth Hepatosplenomegaly SGA Poor suck Lethargy and/or hypotonia
What are the lab findings in congenital CMV?
Increased LFTs (transaminases) Thrombocytopenia
Within what timeframe does diagnosing virologically proven CMV differ from possible CMV?
Less than 3 weeks.
If results positive after 3 weeks, can be either congenital or acquired postnatally.
When do you commence antiviral therapy in congenital CMV infection?
For symptomatic infants (>/=1 symptoms at birth), with virologically-proven CMV infection and at least one end organ system
What is the difference between valgangiclovir and ganciclovir?
Ganciclovir (IV)
Valganciclovir (PO - prodrug to ganciclovir)
What is the definition of avidity and what is its use in congenital CMV?
Avidity = The aggregate strength with which a mixture of polyclonal IgG molecules bind to multiple antigenic epitope of proteins
LOW avidity = Recent primary infection
HIGH avidity = Past infection
What blood type (of both mother and neonate) is most common seen in ABO haemolysis of the newborn?
Mother - O type
Neonate - A type
Naturally occurring antibodies in type A or B mothers are IgM (does not cross placenta as too large). 1% blood O mothers produce IgG
Haemolysis due to anti-A is more common than anti-B
What factors affect drug placental transfer?
- Size - Molecular weight < 600 cross placenta. Most >1000 Da do not (heparin, protamine, insulin)
- Charge - Non-ionised drugs tend to cross more easily
- Protein binding - Generally taught that protein-bound less easily crosses planceta
- Lipiphilicity - Generally advantageous with regards to placental transfer (unless extreme lipophilic as can accumulate in placenta)
How much glucose per minute does a neonate require?
6-8mg/kg/min - Neonate
4-6mg/kg/min - Infant/child
What are drugs that do not cross the placenta?
Insulin
Heparin
All paralytics
Glycopyrrolate
Which site of the placenta is involved in the exchange of nutrients and gases between maternal bloodstream and fetus?
Synctiotrophoblast
What is the most common infectious agent causing neonatal conjunctivitis?
Chlamydia trachomatis
Weakly Gram negative
Obligate intracellular parasites
What is the treatment for chlamydial conjunctivitis?
Oral erythromycin (not topical)
What is the incubation period of neonatal conjunctivitis depending on microbial cause?
N. gonorrhoea = Appears 2-5 days after birth
C. trachomatis = 5-14 days
Non-gonorrheal, non-chlamydia cause= 5-14 days
HSV = Presentation within 2 weeks
What is the treatment for gonorrhea conjunctivitis?
Ceftriaxone (IV/IM)
Gram-negative diplococci (kidney-shaped)
What are the clinical findings in neonatal brachial plexus injuries?
C5. C6 (Erb’s) = Upper arm adducted, IR, forearm extended, hand and wrist normal
C5, C6, C7 (Erb’s plus) = Waiter’s tip posture - As above with flexion of wrist and fingers
C5 to T1 = Arm paralysis with some sparing of finger flexion. Flail arm and Horner if severe
C8, T1 (Klumpke) = Isolated hand paralysis and Horner
Where are brachial cleft cysts found in relation to the sternocleidomastoid muscle?
Anterior
What are some causes of asymmetric vs symmetric IUGR?
Asymmetrical: (70%)
- Chronic high blood pressure
- Severe malnutrition
- Some genetic mutations (Ehler-Danlos, Russell-Silver)
- Multiple gestation
- Abnormal placental structure
- High altitude
- Uteroplacental insufficiency
Symmetrical: (30%)
- Early intrauterine infections
- Chromosomal abnormalities
- Anaemia
- Maternal substance abuse
- Cigarette smoking
- Maternal SLE
- Chromosomal deletions, inborn errors of metabolism
What is the most common bone fracture in neonatal delivery?
Clavicle
Reduced movement and Moro of affected. Usually conservative, rarely requires immobilisation
What is the clinical course of neonatal hepatitis B and how is it prevented?
Usually asymptomatic
- Mild, often persistent raised LFTs at 2-6 months. Small number develop acute hepatitis by 2 months age.
- Most develop chronic infection, which may progress to cirrhosis and hepatocellular carcinoma
Infants with HbsAg positive mothers:
- Universal hepatitis B vaccination
- HBIg (immunoprophylaxis)
Is hepatitis B transferred through breastmilk?
No, breastfeeding not contraindicated. Does not increase transmission
Infection rate 90% in neonates who do not receive prophylaxis who are born to HBV-infected mother
What are the major causes of neonatal mortality?
- Prematurity/low birth weight
- Congenital anomalies
Accounts for 2/3 of all infant deaths
What factors reduce risk of neurodevelopmental impairment or death?
- Higher birthweight
- Female
- Singleton birth
- Antenatal steroids
What are risk factors for subgaleal haemorrhage?
- Prolonged second stage
- Large infants
- Cephalopelvic disproportion
- Neonatal coagulopathy
What are the anatomical boundaries of extracranial injuries?
Caput = Oedematous swelling of soft tissues of the scalp
Cephalohaematoma = Subperiosteal haemorrhage
Subgaleal = Bleed beneath the aponeurosis (serves as insertion for occipitofrontalis muscle)
What is the most serious complication of chronic oligohydramnios?
Pulmonary hypoplasia
How do you interpret maternal serum alpha-fetoprotein?
Elevated MSAFP: 'RAIN' - umbrella R - renal anomalies A - abdominal wall defects I - incorrect dating (most common); multiples (twins) N - neural tube defects
Low MSAFP:
- Trisomies - 13, 18 and 21 (MSAFP is down with Downs)
- IUGR
- Incorrect dating
**Note that incorrect dating can either raise or lower MSAFP depending on whether too early vs. late
What are complications associated with IUGR in the perinatal period?
Preterm delivery Perinatal asphyxia Impaired thermoregulation Hypoglycaemia Polycythaemia and hypervisciosity Impaired immune function Mortality
What factors of the oxygen dissociation curve affect neonatal cyanosis?
Shift to the LEFT:
- Alkalosis (increased pH)
- Hyperventilation (decreased PCO2)
- Cold (decreased temp)
- Decreased 2,3 diphosphoglycerate (DPG)
Shit to the RIGHT:
- Acidosis
- Fever
- Increase in adult Hb
What are the broad pathophysiological causes of central cyanosis in a neonate?
Alveolar hypoventilation
Ventilation-perfusion mismatch
Right-to-left shunting
Diffusion impairment
How do you differentiate a central nervous system disorder vs. neuromuscular disease?
Generally:
CNS disorder = Reduced tone > reduced muscle strength
Neuromuscular disorder = Absent or very reduced antigravity movement
In a neonate with facial nerve palsy, what is the other cranial nerve commonly affected in intracranial injury?
6th nerve palsy
What is the best measure of neonate’s response to heat and cold stress and at what temperature should it be maintained at?
Skin temperature > rectal/core
- Reflects alterations of skin blood flow as initial response before any change in heat production
Aim for abdominal temperature 36 degrees (36.1-36.8)
What are the clinical features of neonatal cold injury?
(Initial)
Apathy, food refusal, oliguria, coldness to touch.
Body temperature 29/5-35.5
Immobility, oedema, redness to extremities, erythema of face
Associated with haemorrhagic manifestations (e.g. pulmonary haemorrhage)
Hypoglycaemia and acidosis common
10% mortality
Treat by warming
What are complications in infants of diabetic mothers?
- Increased risk congenital anomalies (poor metabolic control during periconception and organogenesis; cardiac malformations and lumbosacral agenesis most common; also NTD, hydronephrosis, renal agesis; small left colon syndrome)
- Pre-term delivery
- Perinatal asphyxia (macrosomnia and cardiomyopathy)
- Macrosomnia (excessive nutrients)
- Birth injury (macrosomnia)
- RDS occurs more frequently (delay surfactant production, more likely pre-term)
- Polycythaemia and hyperviscosity (increased EPO) -> renal vein thrombosis
- Low iron stores (inverse to degree of polycythaemia)
- Hyperbilirubinaemia
- Cardiomyopathy (thickening IV septum; usually transient)
- Hypoglycaemia, hypocalcaemia, hypomagnesaemia
What are causes of neonatal cholestasis?
- Biliary atresia (most common; = progressive idiopathic disease of extrahepatic biliary tree)
- Infections (TORCH, UTI)
- Alagille syndrome (= paucity of interlobular ducts; AD)
- Inborn errors of metabolism
- Cystic fibrosis
- Parenteral nutrition
Which maternal immunologic diseases adversely affect the newborn and why?
IgG antibodies.
ITP, SLE, myasthenia and Graves disease
What are available chemical indices for fetal maturity of lungs and kidneys?
Amniotic fluid creatinine (kidney) and lecithin (lung) functions.
Lecithin is produced by alveolar type II cells. Until middle of T3, concentration nearly equals that of sphingomyelin; thereafter sphingomyelin constant while lecithin increases. Thus at 35/40, L:S ratio around 2:1 = mature lung. If < 2:1 = immature
What are significant findings on fetal antenatal USS?
- Dilated cerebral ventricles (hydrocephalus, hydraencepahlous, Dandy-Walker cyst, agenesis corpus callosum)
- Choroid plexus cyst (T21/18, aneuploidy)
- Nuchal pad thickening (T21/18, Turner)
- Dilated renal pelvis (uteropelvic junction obstruction, VUR, PUV, entopic ureterocele)
- Echogenic bowel (CF, aneuploidy)
- Small or absent stomach, or with double bubble (upper GI obstruction, duodenal atresia; >30% with double bubble have T21)
What are the maternal effects of smoking on the neonate/pregnancy?
PREGNANCY
Placental abruption, placenta praevia, preterm labour, LBW, ectopic pregnancy
NEONATE
SIDS, respiratory infections (bronchitis, pneumonia), asthma, atopy, otitis media, infantile colic, short stature, shorter attention spans, childhood obesity, decreased school performance
What is the most serious complication of neonatal lupus?
Complete heart block
2% of newborns of mothers with anti-Ro or La antibodies.
What are the clinical findings of hypermagnesaemia in the newborn?
Usually in neonates whose mothers treated with magnesium sulfate for pregnancy-induced hypertension or tocolysis.
Associated with: 1. Respiratory depression 2. Apnoea 3. Generalised hypotonia Additional complications: 1. GI hypomotility 2. Meconium plug syndrome (mimicking intestinal obstruction)
Typically self limited; levels normalise within several days.
Severe cases = IV calcium and diuretics
What are the fetal effects of intrahepatic cholestasis of pregnancy?
ICP = c/b pruritus and elevation of serum bile acids; typically develops in T2/3; rapidly resolve after delivery. Pruritus predominantly palms and soles, worse at night.
Fetal effects:
- Increased risk intrauterine demise
- Meconium-stained amniotic fluid
- Preterm delivery
- Respiratory distress syndrome (a/w bile acids entering lungs)
Tx (maternal) = ursodeoxycholic acid, given before term
No fetal/neonatal toxicity
What are the features of fetal alcohol syndrome?
= Most common known cause of preventable intellectual disability
Risk factors = alcohol during pregnancy, older maternal age, women of higher parity, poor maternal nutritional status
FEATURES
1. IUGR, microcephaly with growth failure persisting throughout childhood and adolescence
2. Dysmorphic facial features - 3 in DIAGNOSTIC CRIETRIA = small palpebral fissure, thin vermilion border, smooth philtrum
Also: small, upturned nose, broad nasal bridge, hypoplastic midface
3. Increased risk cleft lip +/- cleft palate; micrognathia
4. Septal defects - esp. ASD
5. Renal anomalies
6. Visual and auditory defects
7. MSK findings - 5th finger clinodactyly, fixed flexion of digits, hypoplastic nails
8. Developmental delay, learning disorders, lower IQ (almost all universally present with varying severity)
9. Behaviour disorders (ADHD, poor socialisation)
What is a neonate most at risk of with maternal lithium use?
Cardiac malformations
- Especially Ebstein anomaly = apical displacement of septal leaflet of tricuspid valve and a displace, elongated anterior leaflet
What are the features of fetal hydantoin syndrome?
= use of PHENYTOIN during pregnancy (phenytoin embryopathy)
Category D drug
FEATURES
- Microcephaly, brachycephaly, midface hypoplasia, low-set ears, mild hypertelorism, depressed nasal bridge, cleft lip and palate.
- Digits of hands and feet often hypoplastic
- Cardiac defects - coarctation of aortia, endocardial cushion defect, septal defects
- Increased risk of coagulation defects
- Genitourinary defects
- Increased risk of certain neoplasms - neuroblastoma, mesenchymoma, Wilms tumour
What are neonatal effects of maternal ACEI use?
ACEI contraindicated THROUGHOUT pregnancy - cross placenta and inhibit renin-angiotensin system -> decrease GFR and urine production -
oligohydramnios
FIRST TRIMESTER
Congenital cardiovascular and CNS anomalies = most common
e.g. septal defects, PDA, neural tube defect
SECOND/THIRD TRIMESTER
Renal anomalies = most common
Also fetal growth restriction, oligohydramnios (due to decrease urine production), in utero fetal demise, neonatal renal failure
Surviving infants often have limb and hand anomalies, widely spaced eyes, low-set ears, posteriorly rotated ears, and facial deformities (small chin, beaked nose, unusual facial creases) resulting from compression of fetus in uterus (Potter syndrome)
What is the recommended delivery room temperature for newborns?
23-25 degrees Celsius
as per AAP Committee
What are the teratogenic effects of warfarin?
Nasal hypoplasia
Also more prone to bleeding due to vitamin K antagonism
What drug is associated with neural tube defects?
Antiepileptics
e.g. valproic acid, carbamazepine
NTD = result from failure of neural tube to close spontaneously between 3rd and 4th week in utero development
What drugs are thought to be associated with gastroschisis?
Vasoactive drugs
e.g. cocaine, nicotine, pseudoephidrine
What are the neonatal effects of maternal propanolol use?
Decreased placental perfusion
Fetal bradycardia
Hypoglycaemia
Thrombocytopenia
What is associated with small left colon syndrome?
Maternal diabetes
Seen in infants of diabetic mothers.
= Colonic obstruction involving significant caliber reduction in the sigmoid and descending colon that is unrelated to meconium inspissation or aganglionosis.
Associated with transient inability to pass meconium.
Resolves spontaneously
What are IUGR neonates at risk of later on in (adult) life?
NEURODEVELOPMENT
- Intellectual and neurologic deficit
- Neurodevelopmental impairment (mental retardation, CP, blindness, deafness)
ADULT CHRONIC DISORDERS (Barker hypothesis = Fetal undernutrition results in changes in vascular development) 1. Coronary heart disease 2. Hyperlipidaemia 3. Hypertension 4. Chronic kidney disease 5. Type II DM 6. Obesity 7. Fatty liver disease 8. ?Growth abnormalities
What is the follow-up regimen for infants of HBsAg-positive mothers?
HBIg and HepB vaccine within 12 hours of birth
Completion of HepB vaccine: 1-2 months of age; and 6 months (unless weigh <2000g as birth dose not counted thuerefore 3 additional doses needed beginning at 1-2 months)
Infant tested for anti-HBs and HBsAg at 9-12 months
- > If anti-HBsAg levels >/= 10 mIU/mL: immune; no follow-up
- > If <10 mIU/mL + HBsAg-negative: reimmunised HepB at 2 month intervals; retested for anti-HBsAg 1-2 months after third dose
What are the indications of surgery for an umbilical hernia?
Often associated with diastasis recti.
Most appear before 6 months; disappear by 1 year
INDICATIONS FOR SURGERY
- Persists to age 4-5 years
- Causes symptoms
- Strangulated
- Progressively larger after 1-2 years age
What is the triad for renal vein thrombosis?
TRIAD
- Sudden onset gross haematuria
- Unilateral (usually)/bilateral (results in renal failure) flank mass
- Thrombocytopenia
OTHER SYMPTOMS
Hypertension, microangiopathic haemolytic anaemia, oliguria
CAUSES IN NEWBORNS
Asphyxia, dehydration, shock, sepsis, hypercoagulable states, maternal diabetes
INVESTIGATIONS
- USS - renal enlargement
- Radionuclide studies - little or no renal function
- Doppler flow of IVC and renal vein to confirm diagnosis
Avoid contrast studies
What are causes of craniotabes in a neonate?
= Softened, thinned, flexible area of the cranial bones, usually over the parietal or occipital region
(pressing down sensation like ‘ping-pong’ ball)
CAUSES
Syphillis
Intrauterine crowding
If PERSISTENT >6-9 months, can be: Rickets Hypervitaminosis A Vitamin D deficiency in utero Osteogenesis imperfecta Hydrocephalus
How do you test for congenital syphilis?
SCREENING
(Nontreponemal tests)
- Titers increase with active disease and decline with adequate treatment
1. Veneral Disease Research Laboratory (VDRL)
2. Rapid plasma reagin (RPR)
CONFIRMATORY TESTS
(Treponemal tests)
- Measure specific T. pallidum antibodies (IgG/M/A) which appear earlier than nontreponemal antibodies
- Do not correlate with disease activity
- Usually remain positive for life
1. T. pallidum haemagglutination assay
2. Fluorescent treponemal antibody absorption test
Which types of twins are at risk for twin-to-twin transfusion?
Monozygotic twins with same placenta (i.e. monochorionic)
- Monozygotic twins with dichorionic placentation NOT at risk
- Both can have hydrops fetalis
DIZYGOTIC TWINS
70% twin pregnancies
Always have separate placentas (dichorionic)
Most reliable sign of dizygosity is different sex fetuses
Risk factors: IVF, advanced maternal/paternal age, family history, ethnicity (Nigerian)
MONOZYGOTIC TWINS
30% twin pregnancies
No maternal/paternal age or ethnic predisposition
Time at which separation occurs determines chorionicity and amnionicity
What are two distinguishing features between Apert and Crouzon syndrome?
Both are syndromic carniosynonstosis
Syndactyly in Apert - ‘mitten hand’ fusion of 2nd, 3rd, 4th and sometimes 5th fingers
Ocular proptosis more prominent in Crouzon
What is the associated risk of macrolide antibiotics (erythromycin, azithromycin)?
Pyloric stenosis
What maternal infections are contraindications to breastfeeding?
HIV
Active tuberculosis
Human T-cell lymphotrophic virus types 1 and 2
Herpes virus infection on breast
Maternal treatment with some radioactive compounds
What are the indications for therapeutic hypothermia in HIE?
= 72 hours of hypothermia at 33-35 degrees celsius; started within the first 6 hours after delivery
(only proven neuroprotective therapy for treatment of neonatal encephalopathy)
- GA >/= 36 weeks and = 6 hours age
- pH = 7.0 OR base deficit >/= 16 mmol/L in a sample of umbilical cord blood or any blood obtained within the first hour after birth
- One of the following:
i) a 10-minute Apgar of <5
ii) ongoing resuscitation (assisted ventilation, chest compressions, cardiac medication) initiated at birth and continued for at least 10 minutes - Moderate to severe encephalopathy on clinical examination (Sarnat examination)
What are the indications for mechanical ventilation in neonates?
- Respiratory acidosis (arterial pH <7.2 and PaCO2 >60-65 mmHg)
- Hypoxia (arterial PaO2 < 50mmHg) OR when FiO2 >40% on nCPAP
- Severe apnoea
What are the benefits of providing mechanical ventilation?
Improved gas exchange
Decreased WOB
Provide adequate minute ventilation
What are the XR changes seen with meconium aspiration?
- Increased lung volumes
= hyperinflated with flattened diaphragm; secondary to distal small airway obstruction and gas trapping - Asymmetric patchy pulmonary infiltrate
= due to subsegmental atelectasis; may be ‘ROPE-LIKE’ - Pleural effusion
- Pneumothorax or pneumomediastinum (20-40%)
= due to increased alveolar tension from obstructed airways - Multifocal consolidation
= due to chemical pneumonitis
What conditions are a single umbilical artery associated with?
T18
Cardiac and urogenital abnormalities
In general -> think congenital abnormalities
What is placenta accreta spectrum?
= term to describe abnormal trophoblast invasion into the myometrium of the uterine wall
Results from placental implantation at an area of defective decidualisation typically caused by secondary damage to the endometrial-myometrial surface
PLACENTA ACCRETA
Anchoring placental villi attach to the myometrium (rather than decidua)
PLACENTA INCRETA
Anchoring placental villi penetrate into the myometrium
PLACENTA PERCRETA
Anchoring placental villi penetrate through the myometrium to the uterine serosa or adjacent organs
What is the highest risk factor for preterm delivery?
History of previous preterm delivery
The incidence of congenital malformations in diabetic mothers is related to what?
Degree of maternal hyperglycaemia PRIOR to conception
What is the HbA1c aim both before and during pregnancy?
< 6%
What are the causes of nasal stuffiness in the neonatal period?
Mucus in nostrils
Trauma
Opiate withdrawal
Congenital syphillis (haemorrhagic, thick, purulent)
What are causes of a protruding tongue in a neonate?
Down syndrome Beckwith-Wiedemann syndrome Hypothyroidism Isolated macroglossia Haemangioma
What syndromes are associated with cystic hygroma?
Turner syndrome
Klinefelter syndrome
T13, 18, 21
= lymphangioma caused by abnormal development of the lymphatic system -> obstruction of lymphatic flow and sequestration of lymphatic fluid
Associated karyotypic abnormalities seen in 70%
Oedema/webbing of the neck and widely spaced nipples are seen in what 2 syndromes?
Turner syndrome
Noonan syndrome
What is hemihypertrophy of the limbs associated with?
Wilms tumour
Hepatoblastoma
Adrenal carcinoma
In what syndrome are overriding fingers (index over 3rd; 4th over 5th) seen?
Trisomy 18
In what disease in thumb hypoplasia seen in?
Fanconi anaemia
What are causes of a high-pitch cry in a neonate?
CNS abnormalities (e.g. HIE) Neonatal abstinence syndrome
What syndromes is clinodactyly seen in?
Down syndrome (T21) (5th finger with hypoplastic mid-phalynx)
Fetal alcohol syndrome (5th finger)
Russell-Silver syndrome (5th finger)
In what congenital infection do you see haemorrhagic rhinitis ‘sniffles’?
Congenital syphilis
What is Hutchinson’s triad and what is it a sign of?
Congenital syphilis
Think ‘eye, ear, mouth’
- Malformed teeth (Hutchinson’s incisors, mulberry molar)
- CN VIII deafness
- Interstitial keratitis (corneal scarring due to chronic inflammation of corneal stroma)
