NEWBORN/FETUS Flashcards
Brachial plexus palsy definition
Flaccid paralysis of the arm at birth affecting different nerves of the brachial plexus C5-T1
Brachial plexus palsy MCC, associations
MCC: Birth trauma
Associations:
- Shoulder dystocia
- LGA
- Maternal diabetes
- Instrumental delivery
Brachial plexus palsy counselling
- Not always preventable
- 75% recover completely by 1 month
- 25% experience permanent impairment and disability
Brachial plexus palsy - when to refer?
If not improved by 1 month
Brachial plexus palsy - treatment
Decide surgical vs nonsurgical based on: History, electrodiagnostic procedures, imaging, physical exam
No RCT evidence that primary surgical exploration > conservative management for outcomes, but nonrandomized studies suggest better results with surgical repair
Secondary surgical reconstructions are inferior to primary intervention but can improve function in kids w serious impairment
Secondary soft tissue and bone reconstructive surgery may help improve function if significant impairment but < primary intervention
Hemorrhagic disease of the newborn - presentation
Unexpected bleeding (often GI, ecchymosis, or ICH) due to low vit K from insufficient prenatal storage and insufficient vit K in BM
Types of vitK deficient bleeding
Early <24h - maternal meds (AEDs)
Classic - day 2-7, low vitK intake
Late - 2-12 weeks and up to 6m (50% ICH) 2/2 chronic malabsorption and low intake
Vitamin K deficiency bleeding - prevention?
IM vit K (0.5 if BW <1500 and 1.0 if BW > 1500) within 6h post delivery prevents early and classic
NO evidence for oral vit K supplement in women on AEDs to prevent early
IM > PO (storage, slow release)
PO only for parents who decline IM at birth
Rate of late vitK deficiency bleeding
Risk factor?
1/140,000 - 1/170,000
Breastfeeding
Vitamin K deficiency bleeding and prematurity
Higher risk (hepatic immaturity, delayed gut colonization with bacteria)
routine IV vitK not recommended
What to do if parents decline vitK injection
Counsel on health risks of VDKB:
- PO less effective than IM for prevention
- Making sure infant receives all follow up doses
- Infant remains at risk for VKDB despite use of parenteral form for PO admin
If still decline, give 2.0 mg PO at time of first feed, repeat at 2-4 and 6-8 weeks of age
Circumcision - definition and epidemiology
Partial or complete removal of the foreskin
Rate 32% nationally
Majority by medical practitioners/skilled traditional providers
Circumcision - potential benefits
- Phimosis (scarring/thickening of foreskin that prevents retraction) treatment - medical treatment (topical steroids BID with gentle traction) usually effective, 0.8-1.6% of boys will need circ pre-puberty
- UTI reduction - decreased by 90% in circumcised infants (risk overestimating as contaminated?)
- STI reduction - HIV 50-60% reduction in African subcontinent (unclear in NA as HIV transmitted mainly via IVDU), decreased HSV, HPV, no impact on chlamydia/gon, for female partners lower trich, BV, genital ulcers
- Cancer reduction - reduces female cervical ca risk, squamous cell carcinoma of the penis
Circumcision - risks
Pain Minor bleeding Local infection Unsatisfactory cosmetic result Partial amputation of penis Sepsis/hemorrhage - death very rare Meatal stenosis (2-10%) requires surgical dilation, prevent by applying vaseline for 6m post circ
NO evidence for decreased sexual function/satisfaction
Circumcision - contraindications
Hypospadias
Bleeding diathesis
Normal foreskin retraction
50% by age 6, 95% by age 17
Neonatal ophthalmia - definition
Conjunctivitis occurring within first 4 weeks of life
N. gonorrhea neonatal ophthalmia
- frequency w/o prevention in positive mums
- Complications
30-50%
quickly progresses to corneal ulceration, performation of globe, and permanent visual impairment
C. trachomatis - risks with untreated positive mom, prevention, how to test?
50% will get an infection
- 30-50% risk conjunctivitis
- 10-20% risk of chlamydial pna
- ocular proph does NOT prevent transmission from mum to bb, does NOT prevent conjunctivitis or pna
- routine prenatal screening and treatment during pregnancy preferred
- close clinical follow up and swab infant if suspicion (NP + conjunctival)
Neonatal ophthalmia - frequency of common bugs?
C. trachomatis: 2-40%
N. gonorrhea: <1%
Other (staph, strep, hemophilus, other GNBs): 30-50%
Viral (HSV, adeno, entero)
Ocular prophylaxis with erythromycin?
not routinely recommended
Best prevention strategy for neonatal ophthalmia
Screen all pregnant women for gon/chlamydia,
- Those infected should be treated during pregnancy, tested for cure, and tested again in 3T, partners should also be treated
- Those not infected but high risk should be screened again in 3T
- Rescreening with other STIs should be considered in 3T for women not in a stable monogamous relationship
- Pregnant women not screened during preg should be screened at delivery
How to manage NB exposed to N gonorrhea
- If results not available at dc, ensure ability to contact mother promptly, to monitor for eye discharge, and who to contact if appears; if compliance a concern consider 1x dose of CTX
- Infants born to mums with untreated gonorrhea (inc CS) should be tested and started on treatment without waiting for results:
- term and preterm: Conjunctival culture + single dose CTX 50mg/kg (max 125mg) IV/IM, 1% lido w/o epi (0.45mL/125mg)
- Unwell: blood + CSF cultures
If established gonoccocal disease do ID consult
How to manage NB exposed to C trachomatis
- Untreated (born SVD or CS): Observe, routine cultures not performed on asymptomatic infants, treat if infection occurs
- Proph NOT recommended (association of macrolides w pyloric stenosis) - but consider if infant f/u not guaranteed
