Neonatology Flashcards
In HFOV changing what setting has the highest effect on oxygenation?
Mean airway pressure has the most important effect on oxygenation, as altering to optimal levels will change lung volume, improve VP matching, and decrease shunting.
PaO2 is dependent on Paw (MAP) and FiO2.
PaCO2 is dependent on delta P and frequency.
What is the major component of both naturally occurring surfactant and purified animal derived surfactant for exogenous use?
Dipalmitoylphosphatidylcholine (DPPC), also known as Lecithin
What factors are required to calculate the oxygenation index (OI)?
[FiO2 (%) x Mean airway pressure (mmHg)] / PaO2 (mmHg)
Oxygenation index is useful for objectifying the intensity of ventilation required and the severity of hypoxaemia. >25 is “high” and correlates with severe type 1 respiratory failure, ECMO required
Persistent pulmonary hypertension of the newborn (PPHN)
- Tachypnoea, possible pansystolic murmur (tricuspid regurg), prominent 2nd heart sound
- If significant then >10% pre and post ductal sats discrepancy (pre>post) resulting from R-L shunting via the ductus
- Often idiopathic, but can be due to sepsis, birth asphyxia meconium aspiration, pulmonary hypoplasia, and maternal medications (SSRI+NSAIDs)
What is the most common type of oesophageal atresia?
Type C - oesophageal atresia with a distal TOF (85% of cases)
What proportion of cleft lip and palates are not associated with a syndrome (i.e. non-syndromic)?
70% (in contrast, 50% of isolated cleft palate are not associated with a syndrome, and 90% of isolated cleft lips)
Syndromes associated with cleft palate?
- Stickler syndrome
- 22q11 deletion
- Treacher-Collins syndrome
Signs of congenital zika?
- Microcephaly, intracranial calcifications
- Seizures, spasticity
- Feeding issues, developmental delay
- Contractures and limb abnormalities
- Visual abnormalities
- NOT hepatosplenomegaly
Describe neonatal lupus
- Symptoms: SGA, congenital heart block, cutaneous lesions after UV exposure, hepatitis, thrombocytopenia, neutropenia, pulmonary and neurological disease
- Maternal transfer of SLE IgG autoantibodies, usually anti Ro/SSA or anti La/SSB, between 12-16/40
- Most manifestations resolve, apart from heart block (can use AN and PN steroids)
What develops from the endoderm?
- Internal layer
- Alveolar/lung cells, thyroid, GI, pancreas
What develops from the mesoderm?
- Middle layer
- Cardiac, smooth muscle cells (gut), skeletal muscle, RBC/circulatory system, tubules of kidney
What develops from the ectoderm?
- Outer layer
- Skin, pigment cells, central nervous system
Describe the process of gut formation in the fetus?
- Extra-abdominal gut rotates 270 degrees anticlockwise around the mesentery (containing SMA)
- Failure to complete this results in malrotation and risk of volvulus
- Gut returns to abdomen at 12/40. Errors in this result in gastroschisis and exomphalos
What is a meckel’s diverticulum?
A remnant of the vitelline duct (yolk sac stalk)
Describe the process of neural tube development
- Neural tube forms by 3/40
- Neural groove closes in cranial to caudal direction at end of 4/40
- Myelination of Schwann cells begins at 12/40, increases from 24/40, not complete until age 2
Describe the process of gonadal development
- Y chromosome (SRY gene) influences the development of the gonads after 6/40
- Testes secrete Mullerian inhibiting factor which results in regression of the uterus/vagina/fallopian tubes
- Testosterone influences development of Wolfian structures (prostate, seminiferous tubules, vas deferens)
Risks of maternal diabetes for neonate
- 3 x inc congenital malformations (CHD, sacral agenesis, NTD, microcolon)
- SGA (due to small vessel disease) or LGA (hyperglycaemia)
- Hypoglycaemia, low Ca + Mg
- Surfactant deficiency, polycythaemia, jaundice, transient septal hypertrophic cardiomyopathy
Risks of hypertension/pre-eclampsia for neonate
- SGA
- Polycythaemia
- Neutropenia, thrombocytopenia
- Hypoglycaemia
Risks of maternal thyroid disease for neonate
- Maternal Grave’s causing thyrotoxicosis
- Neonatal hypothyroidism due to maternal anti-thyroid medications
Describe neonatal thyrotoxicosis
- Due to transplacental passage of thyroid-stimulating antibodies from mother with Grave’s disease
- Rare, only 1/70 mothers with thyrotoxicosis
- Can cause goitre, low birth weight, failure to gain weight, tachycardia, restlessness, jitteriness
- Check cord TSH + TSH/T4 at 10-14 days age
- Severe cases treat with beta-blocker and carbimazole
- Self resolves as antibody levels fall
Neonatal thrombocytopenia
- Autoimmune: maternal ITP, mother also has low platelets. If <50 treat IVIG and plt transfusion due to risk ICH. Can’t use Mum’s platelets
- Alloimmune: NAIT, maternal antibodies against father’s platelet antigen, IgG antibodies cross placenta. Risk ICH, treatment IVIG, irradiated maternal platelets/random donor
Risk of maternal myasthenia gravis on neonate
- 10% risk - transplacental passage of ACh receptor antibodies
- Weakness, poor suck, resp distress, ptosis
- Maternal severity doesn’t correlate with baby’s severity
- Diagnosis via antibody assay, EMG, neostigmine test
- Usually presents early, resolves by 2 months of age. May require physio if contractures
- If antibodies absent or symptoms persist then consider congenital myasthenia gravis (AR)
Describe the features of foetal alcohol syndrome
- SGA, IUGR, postnatal growth failure
- Microcephaly, CHD
- Facies: long and smooth philtrum, thin upper lip, micrognathia, ear abnormalities, flat nasal bridge, epicanthic folds, short palpebral fissures
- Intellectual impairment
Describe neonatal abstinence syndrome
- Within 1-2 days, but up to 7-10 days age
- Persists longer with methadone
- Wakefulness, irritability, jitteriness, sneezing, apnoea, tachypnoea, diarrhoea, weight loss, seizures,
high pitched cry - Inc risk SIDS, decr risk surfactant deficiency
- <50% require treatment. Tx PO morphine
Teratogenic effects of phenytoin?
- Fetal hydantoin syndrome
- Broad nasal bridge, hypertelorism, ptosis, ear abnormalities
Teratogenic effects of sodium valproate?
Neural tube defects, fused metopic suture, mid-face hypoplasia, CHD, hypospadius, talipes, GDD, finger/toe abnormalities
Teratogenic effects of isotretinoin and high dose Vit A?
Cleft palate, hydrocephalus, CHD
Teratogenic effects of cocaine?
SGA, prune belly, renal anomalies, cardiac/skeletal/eye abnormalities
What are the causes of oligohydramnios?
- Placental insufficiency + IUGR
- Urinary tract abnormalities
- PROM
- Chromosomal abnormalities, eg trisomies
- Infections
What are the causes of polyhydramnios?
- Maternal diabetes
- Oesophageal atresia
- Abnormal karyotype
- Neuromuscular disease (congenital myotonic dystrophy, SMA, congenital myopathy, Moebius syndrome)
- Congenital diaphragmatic hernia
- Idiopathic
Small salmon pink papules and sepsis is likely due to which organism?
Listeria monocytogenes infection - not susceptible to cephalosporins
(GBS and E. coli are most common cause early-onset sepsis, responsible for 60–70% of cases).
10% of neonates with galactosaemia present with?
E.Coli sepsis
Discuss the role of oestrogen during pregnancy
Comes from placenta, increases as pregnancy progresses. Causes proliferation of uterine smooth muscle, breast development, change in pelvic musculature and ligaments
Discuss the role of progesterone during pregnancy
Increased amount after first trimester, comes from placenta. Relaxes uterine smooth muscle, decreases in final few weeks of pregnancy, triggering onset of labour. Also helps with glandular development of breasts.
Discuss the role of oxytocin during pregnancy
Secreted by the posterior pituitary, released by stimulation of the cervix. Causes contraction of the uterine smooth muscle, and milk secretion/ejection (via contraction of the breast myoepithelial cells)
Discuss the role of prolactin during pregnancy
Secreted by the anterior pituitary, inhibited by oestrogen and progesterone. These decrease post-partum, causes increase in prolactin, causes milk production. Inhibits FSH post-partum, preventing ovulation
When does the ductus arteriosus close?
Functional closure within 15 hours (due to inc PO2, decr prostaglandin E2, decr pulm vascular resistance)
When does the ductus venosus close?
Functional closure within hours, anatomical closure 3/52
Discuss the circulatory changes that occur after delivery
- Expansion of the lungs + inc arterial PO2 causes rapid decrease in pulmonary vascular resistance
- Removal of low-resistance placental circulation causes inc systemic vascular resistance
- Output from RV flows entirely into the pulmonary circulation and shunt through ductus reverses L-R (pulm resistance < systemic resistance)
- High arterial PO2 constricts ductus arteriosus
- Inc volume of pulmonary blood flow returning to the left atrium causes inc LA pressure > RA pressure, functionally closing flap of foramen ovale
What keeps the ductus open during fetal life?
Prostaglandin E2 + I2 (prostacyclin) (note: use prostaglandin E1 infusion to keep ductus open post-natally)
How does nitric oxide work?
In vascular smooth muscle nitric oxide causes inc intracellular cGMP. This leads to smooth muscle relaxation and vasodilation by stimulating cGMP-dependant protein kinase which reduces intracellular calcium
What is the definition of a stillbirth?
In utero death >20/40
How do you calculate the perinatal mortality rate?
Death from 20/40 to 6 days/ per 1000 live and stillbirths
How do you calculate the neonatal mortality rate?
Death of liveborn infants <28 days old/ per 1000 live births
How do you calculate the perinatal mortality rate?
Stillbirth + death <6 days of age per 1000 live and stillbirths
What are the early and late complications of IUGR?
- Early: hypothermia, hypoglycaemia, hypoxia, HIE, polycythaemia, neutropenia, thrombocytopenia, NEC
- Late: metabolic syndrome, HTN, diabetes, increased neurodevelopmental issues, short stature (if severe IUGR)
What are the causes of SGA?
- Maternal - smoking, diabetes, HTN, PET, lupus, altitude
- Placental - insufficiency
- Neonatal - multiple gestation, infection, congenital malformations
What are the early and late complicaitons of IUGR?
- Early: hypothermia, hypoglycaemia, hypoxia, HIE, polycythaemia, neutropenia, thrombocytopenia, NEC
- Late: metabolic syndrome, HTN, diabetes, increased neurodevelopmental issues, short stature (if severe IUGR)
Role of T1 and T2 pneumocytes
- T1 pneumocytes responsible for gas exchange
- T2 pneumocytes produce surfactant after 26/40, line 5-10% of alveolar surfaces
What is the role of surfactant, and what is it made of?
- Lowers surface tension at the air-alveolar interface, preventing end-expiratory alveolar collapse, stimulates lung-host defence mechanisms
- Made of phospholipids (85%), other lipids (10%, help with immune function and absorption) and platelet-activating factor (increases surfactant secretion)
What increases and decreases surfactant levels?
- Decreased: prematurity, males, sepsis, diabetes, 2nd twin, elec C/S, FHx
- Increased: females, PROM, maternal opiate use, IUGR, AN steroids
What are the benefits of maternal antenatal steroids?
- Decrease in: mortality (by 31%), IVH (by 46%), NEC, RDS, requirement for resp support, NICU admission, early onset sepsis
- Give if likely preterm birth 24-34+6/40, also elec C/S up to 38+6/40
- Repeated doses after 7 days. No benefit after 34+6/40
What are the benefits of exogenous surfactant administration?
- Decreased mortality, pneumothoraces, and possibly CLD.
- No effect on IVH
- Give early to those who need it - early but selective (FiO2 >30% and worsening, 200mg/kg for initial dose)
- Benefit with multiple doses
Describe CLD/BPD
- Requirement for resp support >28d or >36/40
- Risk factors: prem, prolonged I+V, barotrauma, O2 toxicity, pneumothoraces, GOR, PIE, PDA, chorioamnionitis, infection (esp CMV)
- Only a few require home O2, weaned by age 1-2y
- Inc risk infection and hospitalisation
- Usually normal exercise tolerance in childhood
- No treatment. Good nutrition important
Describe risks and treatment for meconium aspiration
- RFs: term or post-term, SGA, perinatal asphyxia
- Leads to airway blockage (inc airway resistance, gas trapping, pneumo), chemical pneumonitis, infection (E.Coli), surfactant deficiency/PPHN (lipid content of meconium displaces surfactant from alveolar surface)
- Tx: resp support, surfactant replacement shows benefit but require large doses, ECMO if severe
Risk factors for pneumothoraces in neonates
Prematurity, surfactant deficiency, MAS, pneumonia, pulmonary hypoplasia, 1% of healthy infants
Ventilator adjustments to decrease risk of pneumothroaces
Volume guarantee, lower ventilation pressures, faster rate ventilation with short iTime, surfactant, paralysis of infants fighting ventilator
Describe pulmonary interstitial emphysema (PIE)
- Up to 25% of VLBW infants
- Rupture of overdistended alveoli causes cysts in pulmonary interstitium
- Increased risk if chorioamnionitis
- Ventilation is difficult
- Increased risk of CLD and mortality
What are the causes of pulmonary hypoplasia?
- Primary: rare
- Secondary causes:
- Oligohydramnios (renal agenesis/Potter’s syndrome, PCKD, PUV, renal dysplasia)
- PROM <26/40
- Amniocentesis
- Lung compression (thoracic dystrophy, diaphragmatic hernia, CCAM, pleural effusions)
- Reduced fetal movements (myotonic dystrophy, SMA, congenital myopathy)
- Outcome depends on severity and underlying cause
What are the causes and management of chylothorax?
- Lymph into pleural space - either congenital abnormality of pulmonary lymphatics, or iatrogenic post-op
- Can do AN drainage via intercostal drains - decrease risk of pulmonary hypoplasia, facilitate resus post-delivery
- Reduce chyle volume by using MCFA triglyceride milk formula and octreotide
- May need a period of NBM + TPN to help underlying problem resolve
- Subsequent protein and lymphocyte depletion can cause hydrops and infection
Describe the causes, risk factors, symptoms, and treatment of subglottic stenosis
- Congenital or acquired
- RFs: prem, recurrent intubations/traumatic, GOR, infection, Keloid-forming (black babies), incorrect ET tube size
- Sx: stridor, wheeze, SOB, recurrent croup
- Tx: systemic steroids may help facilitate extubation. Laser or cryotherapy to granulomatous tissue. In severe cases tracheostomy or laryngotracheal reconstruction
What are the benefits of patient-trigger mode ventilation?
- Improves synchronisation with baby’s breathing
- Improves oxygenation
- Decreased risk pneumothorax
- Facilitates weaning from ventilator
What are the benefits of volume guarantee ventilation?
- Reduced mortality
- Decreased BPD, pneumothorax, hypocapnia
- Decreased PVL and ICH
- Reduced time on ventilator
When would you use ECMO?
- In severe resp failure, membrane “lung” used so lungs can rest and recover
- Consider in severe resp failure if: reversible lung disease, >35/40, >2kg, no IVH > grade 1, normal coags
- Use if oxygenation index >40 (mean airway pressure x FiO2 x 100 / PO2)
Describe the presentation and treatment of PDA
- Uncommon in term infants >2/7
- VLBW infants present day 3 life as pulm resistance decreases, increased L-R shunt
- Systolic or continuous murmur, bounding pulses, wide pulse pressure (due to runoff of blood into the pulmonary artery during diastole), active precordium, cardiac failure, apnoea
- CXR: may shoe cardiomegaly, pulmonary plethora
- Tx: indomethacin (decr NEC and CLD). Ibuprofen as effective, and decr SEs (NEC, transient renal failure). Coil/ligation surgery
Causes of hypertension in a neonate?
- Vascular: renal artery or aortic thrombosis (UAC), renal vein thrombosis (mat diabetes), coarctation aorta
- Renal: obstructive uropathy (PUV), dysplastic kidney, PCKD, tumour
- Intracranial hypertension
- Endocrine: CAH, hyperthyroid, neuroblastoma, pheochromocytoma
- Meds: steroids, inotropes, mat. cocaine
What are the risk factors for NEC?
- Prematurity, IUGR, enteral feeding (early high volumes increase risk, no benefit of delayed feeding)
- Hypoperfusion/gut ischaemia
- APH, perinatal asphyxia, polycythaemia, PDA, PROM, CHD, Hirschsprung’s, formula, microbiome altered by antibiotics, lack of antenatal steroid
- Most commonly 2-3rd week of life but in term infants can present within days
Complications and treatment of NEC
- Perforation (20-30%), sepsis, DIC, strictures, recurrence (consider Hirschsprung’s), short gut, lactose intolerance
- Tx: NBM 7-14/7, NGT free drainage, IVF/TPN, triple IV ABs, serial AXR to r/o perforation, surgical - peritoneal drain, laparotomy, resection, ileostomy/colostomy
Describe the NEC triad
Abdominal distension, bloody stools, bile-stained aspirates
What reduces the risk of NEC?
AN steroids, probiotics, breast milk