Neonatology

Question 1

What is the neonatal period?

Answer 1

o	Neonatal period: 4 weeks after due date
o	Preterm: <37 weeks gestation
o	Post-term: >41 weeks gestation
o	LBW: <2.5kg
o	VLBW: <1.5kg
o	ELBW: <1kg

Question 2

What are the cyanotic heart defects?

Answer 2

Right to left shunts and common mixing
o Tetralogy of Fallot
o Transposition of Great Arteries
o AVSD

Question 3

What are the acyanotic heat defects?

Answer 3

o	VSD
o	ASD
o	Persistent arterial duct
o	Pulmonary stenosis
o	Aortic stenosis

Question 4

What are the features of VSD?

Answer 4

o	Asymptomatic
o	Physical signs
	Loud pansystolic murmur at LLSE
	Quiet pulmonary 2nd sound (P2)
o	Echo: demonstrates precise anatomy of the defect- assess haemodynamics using Doppler- no pulmonary hypertension

Question 5

What are the features of large VSDs?

Answer 5

 Heart failure with breathlessness and FTT after 1 week old
 Recurrent chest infections
o Physical signs
 Tachypnoea, tachycardia & enlarged liver (heart failure)
 Active precordium
 Soft pansystolic murmur or no murmur
 Apical mid-diastolic murmur  due to increased flow across mitral valve

Question 6

What are the investigations for VSDs?

Answer 6

 CXR: cardiomegaly, enlarged pulmonary arteries, increased pulmonary vascular markings & pulmonary oedema
 ECG: biventricular hypertrophy by 2 months
 Echo: demonstrates the anatomy of the defect, haemodynamic effects and pulmonary hypertension

Question 7

What are the characteristics of patent ductus arteriosus?

Answer 7

Continuous murmur beneath the left clavicle
murmur continues into diastole because the pressure in the pulmonary artery is lower than that in the aorta throughout the cardiac cycle- the PP is increased, causing collapsing or bounding pulse
Increased pulmonary blood flow with heart failure and pulmonary hypertension

Question 8

What are the investigations for patent ductus arteriosus?

Answer 8

if large and symptomatic features on CXR & ECG are indistinguishable from those seen in a patient with a large VSD- the duct is readily identified on echo

Question 9

What are the characteristics of aortic stenosis?

Answer 9

o	Small volume- slow rising pulse
o	Carotid thrill
o	Ejection systolic murmur maximal at the URSE radiating to the neck
o	Delayed and sort aortic 2nd sound
o	Apical ejection click

Question 10

What are the investigations for aortic stenosis?

Answer 10

o CXR- normal or prominent LV with post-stenotic dilation of ascending aorta
o ECG- LV hypertrophy

Question 11

What are the characteristics of pulmonary stenosis?

Answer 11

o An ejection systolic murmur at the ULSE- thrill may be present
o An ejection click best heard at the ULSE
o When severe, there is a prominent RV impulse- heave

Question 12

What are the investigations for pulmonary stenosis?

Answer 12

o CXR- normal or post-stenotic dilation of pulmonary artery

o ECG- RV hypertrophy – upright T wave in V1

Question 13

What are the characteristics of an atrial septal defect?

Answer 13

o Recurrent chest infections/wheeze
o Arrhythmias- 4th decade onward
o Ejection systolic murmur heard at ULSE- due to increased flow across pulmonary valve
o Fixed and widely split 2nd heart sound- due to right ventricular stroke volume equal in inspiration & expiration

Question 14

What are the investigations for an atrial septal defect?

Answer 14

o CXR- cardiomegaly, enlarged pulmonary arteries and increased pulmonary vascular markings
o ECG- partial RBBB
o Echo- will delineate the anatomy and is mainstay of diagnostic investigations

Question 15

What are the characteristics of TOF?

Answer 15

o Clubbing of the finger and toes will develop in older children
o A loud harsh ejection systolic murmur at the LSE from day 1- with increasing right ventricular outflow tract obstruction, which is predominantly muscular and below the pulmonary valve- the murmur will shorten and cyanosis will increase

Question 16

What are the investigations for TOF?

Answer 16

o CXR- relatively small heart, with an uptitled apex (boot-shaped) due to RV hypertrophy- pulmonary artery ‘bay’, a concavity on the left heart border where the convex-shaped main pulmonary artery and RV outflow would normally be profiled
Decreased pulmonary vascular markings reflecting reduced pulmonary blood flow
o ECG- RV hypertrophy when older
o Echo- will demonstrate cardinal features, but cardiac catherisation may be required to show the detailed anatomy of the coronary arteries

Question 17

What are the characteristics of coarctation of the aorta?

Answer 17

o Asymptomatic
o Systemic hypertension in the right arm
o Ejection systolic murmur at USE
o Collaterals heard with continuous murmur at the back
o Radio-femoral delay- due to blood bypassing the obstruction via collateral vessels in the chest wall and hence the pulse in the legs is delayed

Question 18

What are the investigations for coarctation of the aorta?

Answer 18

o CXR- rib-notching due to development of large collateral intercostal arteries running under the ribs posteriorly to bypass the obstruction-‘3’ sign with visible notch in the descending aorta at the site of the coaractation
o ECG- LV hypertrophy

Question 19

What are the characteristics in transposition of the great arteries?

Answer 19

o Cyanosis is always present
o The 2nd heart sound is often loud & single
o Usually no murmur- but may be a systolic murmur from increased flow or stenosis within the LV outflow tract

Question 20

What are the investigations for transposition of the great arteries?

Answer 20

o CXR- narrow upper mediastinum with an ‘egg on side’ appearance of the cardiac shadow, due to the anteroposterior relationship of the great vessels, narrow vascular pedicle and hypertrophied right ventricle respectively
Increased pulmonary vascular markings are common due to increased pulmonary blood flow
o Echo- demonstrates the abnormal arterial connections and associated abnormalities

Question 21

What are the characteristics of ASD?

Answer 21

o Presentation on antenatal US screening
o Cyanosis at birth or heart failure at 2-3 weeks of life
o No murmur heard- the lesion being detected on routine echo in a newborn with Down syndrome
o Always a superior axis on ECG

Question 22

Which heart defects are Downs and Turners associated with?

Answer 22

• Down syndrome: associated with AVSD & VSD with 30% incidence
• Turner syndrome: associated with aortic valve stenosis and coarctation of the aorta in 15%