Neonatology Flashcards
Before what week are babies classed as premature?
<37 weeks
What acute problems can premature babies present with?
Hypothermia Hypoglycaemia and calcaemia Necrotising Enterocolitis Respiratory problems PDA Intraventricular haemorrhage Infection Haematological problems Retinopathy of prematurity
Why can premature babies get hypothermia?
Lack of subcutaneous fat and inability to shiver
What respiratory problems are seen in premature babies?
RDS
Pneumothorax
Apnoea
What haematological problems are seen in neonates?
Anaemia - iron deficiency
Jaundice
What causes respiratory distress syndrome of the newborn?
Lack of surfactant meaning lungs are non-compliant and stiff
Alveoli are immature and few in number
What are the risk factors of Respiratory Distress Syndrome?
Diabetic mother
C Section
How does Respiratory Distress Syndrome present?
Signs of respiratory distress - struggle to breathe, tracheal tug etc.
CXR - ground glass appearance, air bronchograms, indistinct heart border
How is Respiratory Distress Syndrome managed?
O2
Ventilate - Vapotherm, CPAP then BiPAP
Exogenous surfactant - ET tube
Dexamethasone 48hr prior to delivery
What is the aetiology of necotising enterocolitis?
Not fully known. Insult to intestinal mucosa allow commensals to spread
Potentially infective but many have negative culture
How does necrotising enterocolitis present?
Within first 2 weeks
Feeding difficulty Bilious vomiting Abdo distention Bloody mucoid stool Visible bowel loops
What would an AXR of necrotising enterocolitis show?
Thickened bowel wall
Gas filled loops
What differentials for necrotising enterocolitis would you consider?
Volvulus/malrotation
Intussusception
Haemolytic disease
Meconium ileus
How is necrotising enterocolitis managed?
Nil by mouth
NG tube - decompress
IV fluids and TPN
Gentamicin/cefotaxime + metronidazole
What complications are associated with necrotising enterocolitis?
Perforation
Sepsis
DIC
Short bowel syndrome
What causes intraventricular haemorrhage in premature babies?
Unknown but thought to be due to shearing of bridging veins
How does an intraventricular haemorrhage present?
Bradycardia
Cyanosis
Apnoea
Bulging fontanelle within first few days
How is a diagnosis of intraventricular haemorrhage made?
Cranial USS
What is the management plan for an intraventricular haemorrhage?
Supportive management
Describe the aetiology of retinopathy of prematurity
Re-oxygenation following hypoxia means O2 sats increase. This causes proliferation of vessels between vascular and non-vascular retina.
What visual changes can occur in retinopathy of prematurity
Decreased visual acuity
Retinal detachment
Blindness
How is retinopathy of prematurity managed?
O2 therapy minimised
All preterm see ophthalmologist
Laser photocoagulation
What are the long term problems associated with prematurity?
1/4 have hearing impairment
Increased risk of recurrent RTI’s
Behavioural and psychomotor problems - esp. concentration and processing power
When is neonatal jaundice worrying?
<24 hours
>14 days
What are the main causes of jaundice <24 hours after birth?
Haemolysis
Infection
What haemolytic conditions are you worried about?
Rhesus/ABO mismatch
Spherocytosis
G6PD
Haemolytic disease of the newborn
What test would you use to rule out a haemolytic cause to jaundice?
Direct Coomb’s test
G6PD levels
Where could an infection come from in a neonate <1 day old?
Mothers GU tract
Amniotic fluid
TORCH - toxoplasmosis, rubella, CMV, herpes
If a child is jaundiced between days 2-14, what is the most likely reason?
Physiological - Fetal Hb breakdown and immature liver
What are you worried about if a child has prolonged jaundice?
Congenital hypothyroidism Breast milk jaundice Biliary atresia Galactosaemia Infection
What investigations would you carry out on a well baby presenting with jaundice at day 2-3?
Serum bilirubin
What investigations would you request for a poorly baby presenting with either early or prolonged jaundice?
Bilirubin LFT Infection screen TFT Galactosaemia screen Direct Coombs Blood film G6PD
How is neonatal jaundice managed?
Supportive - so they don’t become dehydrated!
Phototherapy - convert unconjugated to conjugated so bilirubin excreted
Exchange transfusion - umbilical artery/vein
What are the disadvantages to phototherapy?
Disrupt maternal bonding
Dehydration
Rash
What is kernicterus?
Bilirubin induced disorder of the brain.
Bilirubin crosses BBB and deposit in basal ganglia and brainstem causing neurological signs
How common is kernicterus?
Very very rare! Jaundice is now very well managed
What babies are classified as small for gestational age?
10th centile birth weight
What are the possible aetiologies for babies that are small for their gestational age?
Baby have low growth at all stages - healthy, could be due to maternal size and ethnicity
Baby growth restricted by chromosomal factors or inborn errors in metabolism
Baby grow normally through first half but slow in at least 2 measurements due to intrauterine growth restriction.
What are the risk factors for a baby being small for its gestational age?
Mother >40 Maternal smoking/drug use Maternal low weight/vigorous exercise Maternal HTN, renal disease or anaemia Pre-eclampsia
How can small gestational age babies be predicted?
Symphysis-fundal height measurements
Uterine artery doppler
How is SGA prevented/managed?
Smoking cessation advice
Single course antenatal steroids
Aspirin before 16 weeks if risk of pre-eclampsia
Progesterone given to prevent pre-term birth
What is intrauterine growth restriction?
A clinical definition of neonates born with growth restriction and features of malnutrition irrespective of their birth weight percentile
What are the risk factors for intrauterine growth restriction?
Similar to those for SGA and
Interpregnancy interval <6 months and >120 months
Mum <16yo
TORCH
What signs are indicative of intrauterine growth restriction?
Large head with large wide anterior fontanelle
Long finger nails
Loose, dry, easily peel-able skin
Small/scaphoid abdomen
Poor skeletal muscle mass and subcutaneous fat - thin arms and legs
Loose fold of skin in nape of neck, axilla, inter-scapular area and groins
Large thin hands and legs (relative)
Thin umbilical cord
Poor breast bud formation
No buccal fat
If the signs of Intra Uterine Growth Restriction are symmetrical, what does this indicate?
Cause of IUGR was early in pregnancy so all measurements equally reduced
Poor prognosis
If signs of Intra Uterine Growth Restriction are asymmetrical, what does this indicate?
Cause of IUGR late in pregnancy
Good prognosis
How do infections spread to neonates?
Vertical transmission
What does infection spread via vertical transmission?
Spread across placenta
Ascending maternal infection and chorioamnionitis
Acquired at birth via genital or haematogenous spread
Can spread postnatally via breast feeding
What protection do neonates have against infection?
Maternal IgG cross placenta
Why are preterm babies more at risk of infection?
Process of maternal IgG crossing is less complete
What are the long term complications associated with a neonatal infection?
Neurodevelopmental delay
Aminoglycoside use - hearing problems
Oxygen therapy - retrolental fibroplasia (eye problems)
What infections are screened for and how are they treated?
Hep B - Hep B vaccine and Ig given at birth
Syphilis - Benzylpenicillin to mum
HIV - antiretroviral treatment for mum and baby
UTI - give Abx to mum
What is the most common cause of severe neonatal infection?
Group B Strep
When and how are neonates exposed to group B strep?
In labour
20-40% of mothers have GBS in bowel
25% have GBS in vaginas
How would group B strep infections normally present?
Within first week but can be upto 3 months
Sepsis, pneumonia or meningitis
What are the risk factors for Group B strep infection?
Premature delivery
Premature rupture of membranes
Previous sibling with GBS infection
Maternal pyrexia
How are group b strep infections prevented?
Routine screening not offered to all women
Testing late in pregnancy (35-37 weeks) if previous GBS detection
Maternal IV Benpen prophylaxis offered if:
Previous GBS detection
Preterm labour
Fever >38 during labour
How is chicken pox transmitted?
Transplacental
Ascending vaginal
Contact with lesion at delivery
When does the most severe chicken pox rash occur in neonates?
<7 days after delivery
How is neonatal chicken pox managed?
Varicella zoster Ig or IV acyclovir if symptomatic
What commonly causes neonatal skin infections?
Staph aureus
When are skin infections high risk in neonates?
If peri-umbilical as can pass up umbilical vein causing thrombophlebitis
What STD’s can neonates get?
Syphilis
Chlamydia
Gonorrhoea
Genital herpes
How does neonatal syphilis present?
Rhinitis
Osteitis
Skin bullae
How does neonatal chlamydia present?
Pneumonia and conjunctivitis
Transmitted at delivery
How does neonatal gonorrhoea present? What is it associated with?
Conjunctivitis
Associated with increased risk of premature pregnancy
How is genital herpes acquired in neonates?
During vaginal delivery
Why is genital herpes very severe in neonates?
Cause:
Seizures
Critical illness
Meningoencephalitis
Coagulopathies
What do you do if you know a pregnant woman has genital herpes?
IV acyclovir
C-Section (most asymptomatic so wouldn’t know)
What is in the Apgar score?
Appearance Pulse Grimace Activity Respiration
Each scored out of 2 - 10 is healthy
When is an Apgar score used?
1, 5 and 10 mins after birth
What do Apgar scores indicate?
0-3 - very low score, may need resuscitation
4-6 - moderately low score
7-10 - baby in good state
What are the signs an infant is floppy?
Feel limp and floppy
Arms and legs straight - should be flexed
When help under armpits, arms rise so baby slip through
Poor feed - can’t suck and swallow
Hyperflexible joints
Head leg
What are the potential causes for a floppy baby? (broad categories)
CNS problem Motor neurone Muscle problem NMJ issue Other
What CNS problems can lead to a baby being floppy
Chromosome abnormalities - Prader Willi. Downs, Noonans, Fragile X
Hypoxic-ischaemic injury
Congenital hypothyroidism
What motor neurone issues can a neonate get?
Spinal Muscular Atrophy (SMA)
What NMJ dysfunction can occur in babies?
Myasthenia gravis
What muscular issues can babies have?
Myotonic dystrophy - Duchenne or Beckers
What investigations would you do for a floppy baby?
MRI
CT
EEG
Bloods etc
If a floppy baby had dysmorphic features, what would you think?
Likely to be due to chromosomal abnormality
If a floppy baby had a large anterior fontanelle, what would you think?
Hypothyroidism
If a floppy baby had drooping eyelids, what would you think?
Myasthenia gravis
If a floppy baby had tongue fasciculations, what would you think?
SMA
If a floppy baby had hypogonadism, what would you think?
Prader-Willi
