Part 11A. The fetus and neonatal infant Flashcards
1st half or so of the part.
1
Q
Definition of live birth
A
Complete expulsion of the productions of conception from the uterus and 1 of 3 criteria:
1. detection of cardiac activity (by ausculta- tion or palpation of the umbilical cord stump),
2. definite movement generated by voluntary muscle contraction, or
3. any respiratory effort.
2
Q
Perinatal period
A
from the 28th wk of pregnancy through the 7th postpartum day
3
Q
Neonatal period
A
spans the 1st 28 days of life and can be further subdivided into early neonatal (1st 7 days) and late neonatal (days 8-28)
4
Q
Primary causes of mortality during the perinatal and neonatal periods.
A
Preterm birth, and congenital malformations
5
Q
Primary cause of mortality during the rest of infancy?
A
unsafe sleep practices
6
Q
Leading etiology of infant deaths from congenital malformation
A
Congenital heart disease
7
Q
What is the most common morbidity of prematurity among NICU survivors?
A
Bronchopulmonary dysplasia
8
Q
The most powerful predictor of BPD is ?
A
Gestational age.
Oxygen exposure and treatment with positive pressure ventilation also increase the risk of developing BPD at any gestational age.
9
Q
Most common sites of necrotizing enterocolitis.
A
distal ileum an ascending colon
10
Q
These are deeper, blue masses that, if large, may trap platelets and produce disseminated intravascular coagulation or interfere with local organ function.
A
Cavernous hemangiomas
11
Q
In many neonates, these are small, white papules on an erythematous base develop 1-3 days after birth.
A
erythema toxicum, may persists for as long as 1 wk, contains eosinophils, and is usually distributed on the face, trunk, and extremities
12
Q
These is a benign lesion seen predominantly in black neonates, contains neutrophils and is present at birth as a vesiculopustular eruption around the chin, neck, back, extremities, and palms or soles; it lasts 2-3 days
A
pustular melanosis
13
Q
This appears as a circular boggy area of edema with indistinct borders and often with overlying ecchymosis.
A
Caput succedaneum, is caused by scalp pressure from the uterus, cervix, or pelvis,
14
Q
This presents as a well-circumscribed fluid-filled mass that does not cross suture lines.
A
Cephalhematoma, not present at delivery but develops over the first few hours of life
15
Q
This head finding in a newborn is not restricted by the boundaries of the sutures and therefore is larger and more diffuse.
A
Subgaleal hemorrhage, extensive bleeding from this may cause hypovolemic shock
16
Q
This is identified as a hard nonmovable ridge over the suture and an abnormally shaped skull.
A
Cranial synostosis - premature fusion of sutures
17
Q
In the newborns, atrophic or alopecic scalp areas may represent?
A
Aplasia cutis congenita
18
Q
Symmetric facial palsy in the newborn suggests what condition?
A
absence or hypoplasia of the 7th nerve nucleus (Möbius syndrome)
19
Q
A cornea >1 cm in diameter in a term infant (with photophobia and tearing) or corneal clouding suggests?
A
Congenital glaucoma
20
Q
What does presence of leukokoria in the newborn suggest?
A
cataracts, tumor, chorioretinitis, retinopathy of prematurity, or a persistent hyperplastic primary vitreous
21
Q
These are temporary accumulations of epithelial cells on the hard palate on either side of the raphe.
A
Epstein pearls
22
Q
This condition in the neonate causes the head to turn toward and the face to turn away from the affected side
A
Congenital torticollis
23
Q
Transitory murmurs in a neonate usually represent
A
a closing ductus arteriosus
24
Q
Routine screening for critical CHD using pulse oximetry is performed when?
A
between 24 and 48 hr of life,
25
Pulse oximeter placement in CCHD screening
Right hand, and either foot
*Pulse oximetry screening with SO2 of ≥95% in the right hand or either foot and < 3% difference between the right hand and foot is considered a normal screening test. *
26
# In the neonate
gas should normally be present in the rectum on radiograph by ?
24 hr of age
27
What is the cause of most neonatal abdominal masses?
Renal pathology
28
Components of the APGAR score
Color, Heart rate, Muscle tone, Respiration, Reflex irritability
(Activity, Pulse, Grimace, Appearance, Respiration)
29
What is the optimal method of maintaining temperature in the stable newborn?
Skin-to-skin contact with the mother
30
What the most frequent pathogenic bacteria to colonize the umbilical cord?
*Staphylococcus aureus*
31
What does application of a 1 cm ribbon of erythromycin (0.5%) or tetracycline (1.0%) sterile ophthalmic ointments in each lower conjunctival sac prevent?
gonococcal ophthalmia neonatorum
32
Screening for hypoglycemia should be performed in
infants who are small for gestational age, large for gestational age, born to mothers who have diabetes, preterm, or symptomatic
33
This technique may provide the most effective analgesia compared with other techniques in doing neonatal circumcision
subcutaneous **circumferential ring block** involves 0.8 mL of 1% lidocaine without epinephrine injected at the base or midshaft of the penis
34
Infant medical contraindications to breastfeeding
Galactosemia
Maple syrup urine disease
Phenylketonuria
35
Maternal conditions that contraindicate breastfeeding include...
infection with human T-cell lymphotropic virus types 1 and 2, active tuberculosis (until appropriately treated ≥2 wk and not considered contagious), herpesvirus infection on breast, use of or dependence on certain illicit drugs, and maternal treatment with some radioactive compounds
36
Pregnancies in both teenagers and women older than 40, particularly primiparous women, are at increased risk for
IUGR, fetal distress, preeclampsia, stillbirth
37
The most serious complication of oligohydramnios
pulmonary hypoplasia
38
An elective CS birth should be delayed until ____ AOG, assuming there is no indication for delivery earlier
> 39 weeks
39
What are the effects on the fetus/neonate if a mother has SLE?
Congenital heart block, rash, anemia, thrombocytopenia, neutropenia
40
What is the most effective method of pregnancy dating during the first trimester?
crown-rump length measurement
41
If only a single US is done during pregnancy, when can the most information be obtained?
18-20 wks AOG, when both gestational age and fetal anatomy can be evaluated
42
When US is used for dating, the most accurate assessment of gestational age is?
by first-trimester (≤1367 wk) US measurement of crown-rump length, which is accurate to within 5-7 days.
43
The predominant cause of antepartum fetal distress is?
uteroplacental insufficiency, which may manifest clinically as IUGR, fetal hypoxia, increased vascular resistance in fetal blood vessels, and, when severe, mixed respiratory and metabolic (lactic) acidosis.
44
What does a reactive (normal) non-stress test show?
2 FHR accelerations of at least 15 beats/min above the baseline FHR lasting 15 sec during 20 min of monitoring.
45
In fetal heart rate monitoring, these are a physiologic vagal response to uterine contractions, with resultant fetal head compression, and represent a repetitive pattern of gradual decrease and return of the FHR that is coincidental with the uterine contraction
Early decelerations
46
Variable decelerations are characterized by a V or U shaped pattern, are abrupt in onset and resolution, are associated with ?
Umbilical cord compression
47
These are characterized by onset after a uterine contraction is well established and persists into the interval following resolution of the contraction. What is this associated with?
Late decelerations are associated with fetal hypoxemia
48
What is the most common congenital infection?
Cytomegalovirus (CMV)
49
The most common complication of congenital CMV infection
Congenital hearing loss
50
Maternal autoantibodies to the folate receptor are associated with ?
Neural tube defects (NTDs)
51
Maternal immunologic sensitization to fetal antigens may be associated with?
neonatal alloimmune hepatitis and neonatal alloimmune thrombocytopenia (NAIT)
52
The administration of diethylstilbestrol during pregnancy causes and increased risk for?
vaginal adeno- carcinoma in female offspring in the 2nd or 3rd decade of life.
53
Smoking during pregnancy is associated with?
IUGR, facial clefts
54
What occurs in the setting of opioid maintenance treatment or illicit drug use?
Neonatal Abstinence Syndrome
55
What s considered first-line therapy for treatment of opioid dependence in pregnancy?
Methadone.
Buprenorphine is an alternative
56
Maternal ingestion of an excessive amount of iodide or propylthiouracil can cause ____ in the fetus?
Hypothyroidism
57
When is an amniocentesis usually done?
between the 15th and 20th wk of gestation
58
The most common indication for genetic amniocentesis is?
Advanced maternal age
59
What is used to diagnose fetal hematologic abnormalities, genetic disorders, infections, and fetal acidosis ?
__Cordocentesis or percutaneous umbilical blood sampling (PUBS)__
The predominant indication for this procedure is for confirmation of fetal anemia (in Rh isoimmunization) or thrombocytopenia (NAIT), with subsequent transfusion of packed red blood cells or platelets into the umbilical venous circulation.
60
What is the screening test with a higher PPV than any other prenatal screening test for Down syndrome?
fetal karyotyping by analysis of fetal DNA in maternal plasma
61
What is recommended in pregnancies deemed to be at risk of imminent delivery before 32 wk gestation in light of evidence demonstrating a reduction in frequency of cerebral palsy compared to those who did not receive this treatment?
Maternal administration of magnesium sulfate for fetal/neonatal neuroprotection
62
It is recommended that women without a prior history of a NTD ingest how much folic acid throughout their reproductive years?
400 μg/day
63
Women with a history of a prior pregnancy complicated by an NTD or a first- degree relative with an NTD should have preconceptional counseling and should ingest how much of supplemental folic acid beginning when?
4 mg/day, at least 1 mo before conception
64
Women taking certain antiepileptic drugs (valproate, carbamazepine) during pregnancy should ingest how much folic acid daily in the preconception period?
1-5mg
65
Most common cause of obstructive uropathy in children?
__Posterior urethral valves (PUVs)__
Other causes: urethral atresia, persistent cloaca, caudal regression, and megacystis– microcolon–intestinal hypoperistalsis syndrome
66
The primary objective of fetal intervention in fetuses with obstructive uropathy is?
restoration of amniotic fluid volume to prevent pulmonary
hypoplasia
67
Obstructive uropathy usually presents on fetal US with?
an enlarged bladder, bilateral hydroureteronephrosis, and oligohydramnios
68
For fetuses with obstructive uropathy who still have adequate renal function and are capable of producing urine, this fetal therapy is the most common and involves percutaneous, US-guided placement of a double-pigtailed shunt from the fetal bladder to the amniotic space, allowing decompression of the obstructed bladder and restoration of the amniotic fluid volume.
Vesicoamniotic shunting
This may improve perinatal survival, but at the expense of poor long-term renal function.
69
This fetal therapy for obstructive uropathy allows for direct visualization of the obstruction and does not require amnioinfusion.
**Fetal cystoscopy.**
when the obstruction is visualized and the diagnosis of PUV confirmed, the valves can be treated, restoring urine flow to the amniotic space and eliminating the need for repeated fetal interventions in most patients.
70
Fetal therapy for nonobstructive renal disease.
Serial amnioinfusions
71
Current approach to fetal therapy for CPAM?
single or multiple courses of antenatal corticosteroids in fetuses with CVR (CPAM volume ratio) >1.6.
| CVR, index that compares the vol. of CPAM to the fetal head circumfer
72
The lowest risk of neonatal and infant mortality occurs in infants with?
| Birthweight, AOG
birthweight of 3,000-4,000 g and a gestational age of 39-41 wk
73
The highest risk of neonatal and infant mortality occurs in infants with
birthweight < 1,000 g and/or with gestational age < 28 wk.
74
In twin gestations, combination of artery-to-artery and vein-to-vein anastomoses is associated with the condition of acardiac fetus. This rare lethal anomaly (1 in 35,000) is secondary to?
the twin reversed arterial perfusion (TRAP) syndrome.
75
In this condition, an artery from one twin acutely or chronically delivers blood that is drained into the vein of the other.
__twin-twin transfusion syndrome (TTTS)__
The latter develops polyhydramnios, plethoric and large for dates, and the former has oligohydramnios, anemic and small
| more common in monozygotic twins
76
Treatment of Twin-Twin Transfusion syndrome includes?
| 4 possible answers
maternal digoxin, aggressive amnioreduction for polyhydramnios, selective twin termination, and more often, laser or fetoscopic ablation of anastomosis
77
Maintaining a relative humidity of ____ aids in stabilizing body temperature by reducing heat loss at lower environmental temperatures
40 - 60 %
78
After the initial resuscitation period, ideal target O2 saturation limits for ELBW infants should be within the range of ____ for most infants.
90–95%
79
A minimum of ____of amino acids should be given in the 1st 24 hr after birth of a high-risk infant
2g/kg, with the goal of supplying at least 3.5 g/kg within 24-48 hr after birth
| To meet total energy requirements, IV lipids will also be needed
80
# Potential Adverse Reactions to Drugs Administered to Premature Infants
Erythromycin
Pyloric stenosis
81
# Potential Adverse Reactions to Drugs Administered to Premature Infants
Furosemide
Deafness, hyponatremia, hypokalemia, hypochloremia, nephrocalcinosis, biliary
stones
82
# Potential Adverse Reactions to Drugs Administered to Premature Infants
Oxygen
Retinopathy of prematurity, bronchopulmonary dysplasia
83
# Potential Adverse Reactions to Drugs Administered to Premature Infants
Chloramphenicol
Gray baby syndrome—shock, bone marrow suppression
84
# Potential Adverse Reactions to Drugs Administered to Premature Infants
NaHCO3
Intraventricular Hemorrhage
85
# Potential Adverse Reactions to Drugs Administered to Premature Infants
Indomethacin
Oliguria, hyponatremia, intestinal perforation
86
Major neonatal morbidities associated with prematurity
* Bronchopulmonary dysplasia
* Necrotizing enterocolitis
* Intraventricular hemorrhage
* Periventricular leukomalacia
* Retinopathy of prematurity
* Infections
87
Late preterm infants
Infants born between 34 and 36 6/7 wk PMA
88
Extremely preterm infants
born before 28 wk gestation
89
# True or FAlse
ACOG recommends a single course of antenatal corticosteroids for pregnant women between 34 and 36 6/7 wk gestation at risk for preterm birth within 7 days, who have not received a previous course of antenatal corticosteroids
True
90
ACOG recommends elective delivery without medical indications only after ____ wk gestation in well-dated pregnancies.
39
91
Infants with IGF-1 receptor defects, pancreatic hypoplasia, or transient neonatal diabetes have?
Intrauterine growth restriction (IUGR)
92
# Readiness for Discharge of High-Risk Infants Criteria
Growth should be occurring at steady increments, with a goal weight gain of approximately ____ g/day
30
93
# Readiness for Discharge of High-Risk Infants Criteria
Infants should have had no recent episodes of apnea or bradycardia requiring intervention for at least ____ days prior to discharge.
5-7
94
# Readiness for Discharge of High-Risk Infants Criteria
All infants with birthweight < ____ g or gestational age < ____ wk at birth should undergo an eye examination to screen for ROP.
1500g
30wk
95
# Readiness for Discharge of High-Risk Infants Criteria
If all major medical problems have resolved and the home setting is adequate, premature infants may then be discharged when their weight approaches ____ , they are > ____ PMA...
1,800-2,000 g
> 34-35 wk
96
It is important to note that for at least the 1st 2 yr of life, a child’s ____ age should be used in determining if a delay exists.
**Corrected age.** It is calculated by subtracting the weeks born premature from a child’s chronological age
97
What is nonprogressive but permanent disorder of movement and posture caused by disturbance to the developing immature brain?
Cerebral Palsy.
98
How to differentiate seizures from jitteriness?
In jitteriness, an examiner may stop the tremors by holding the infant’s extremity; jitteriness often depends on sensory stimuli and occurs when the infant is active, and it is not associated with abnormal eye movements. Tremors are often more rapid with a smaller amplitude than those of tonic-clonic seizures
99
These are characterized by recurrent oral-buccal-lingual movements, rotary limb activities (rowing, pedaling, swimming), tonic posturing, or myoclonus.
## Footnote
A possible consequence of birth asphyxia
**Motor automatisms.**
These motor activities are not usually accompanied by time-synchronized EEG discharges, may not signify cortical epileptic activity, respond poorly to anticonvulsant therapy, and are associated with a poor prognosis.
100
Shortly after birth, lethargy is most likely caused by?
maternal medications (opioids, magnesium, general anesthesia) or severe HIE.
101
Lethargy with emesis suggests?
Increased ICP or an inborn error of metabolism
102
Lethargy appearing after the 2nd day should suggest?
infection or an inborn error of metabolism manifesting with hyperammonemia, acidosis, or hypoglycemia.
103
Typically, ____ of deoxyhemoglobin must be present in the blood for central cyanosis to be clinically apparent.
| in g/dL
5 g/dL
104
Cyanosis unaccompanied by obvious signs of respiratory difficulty suggests?
cyanotic congenital heart disease or methemoglobinemia
105
Bilious emesis strongly suggests obstruction below ____ and warrants urgent contrast-enhanced radiography
the ampulla of Vater
106
Where is the bleed in cephalhematoma?
Subperiosteal
107
Where does IVH in premature infants occur?
in the gelatinous subependymal __germinal matrix__
108
What condition is usually clinically asymptomatic until the neurologic sequelae of white matter damage become apparent in later infancy as spasticity and/or motor deficits?
**Periventricular leukomalacia (PVL)**
It is characterized by focal necrotic lesions in the periventricular white matter and/or more diffuse white matter damage.
109
Describe the different grades of IVH
| Severity of hemorrhage on cranial imaging. Grades I-IV
* Grade I hemorrhage: bleeding is isolated to the subependymal area.
* Grade II hemorrhage, there is bleeding within the ventricle without evidence of ventricular dilation
* Grade III hemorrhage is IVH with ventricular dilation
* Grade IV hemorrhage, there is intraventricular and paren- chymal hemorrhage
110
The prophylactic administration of low-dose ____ to VLBW preterm infants reduces the incidence of severe IVH
indomethacin (0.1 mg/kg/day for 3 days)
111
What is the preferred method to treat progressive and symptomatic post hemorrhagic hydrocephalus (PHH)?
Insertion of a ventriculoperitoneal shunt
112
# HIE in term infants
Level of consciousness
| Findings in the 3 stages
1: Hyperalert
2: Lethargic
3: Stuporous, coma
113
# HIE in term infants
Muscle tone
| Findings in the 3 stages
1: Normal
2: Hypotonic
3: Flaccid
114
# HIE in term infants
Posture
| Findings in the 3 stages
1: Normal
2: Flexion
3: Decerebrate
115
# HIE in term infants
Tendon reflexes / Clonus
| Findings in the 3 stages
1: Hyperactive
2: Hyperactive
3: Absent
116
# HIE in term infants
Myoclonus
| Findings in the 3 stages
1: Present
2: Present
3: Absent
117
# HIE in term infants
Moro Reflex
| Findings in the 3 stages
1: Strong
2: weak
3: ABsent
118
# HIE in term infants
Muscle tone
| Findings in the different stages
1: Normal
2: Hypotonic
3: Flaccid
119
# HIE in term infants
Posture
| Findings in the different stages
1: Normal
2: Flexion
3: Decerebrate
120
# HIE in term infants
Tendon Reflexes
| Findings in the different stages
1: Hyperactive
2: Hyperactive
3: Absent
121
# HIE in term infants
Moro Reflex
| Findings in the different stages
1: Strong
2: Weak
3: Absent
122
# HIE in term infants
Pupils
| Findings in the different stages
1: Mydriasis
2: Miosis
3: Unequal, poor light reflex
123
# HIE in term infants
EEG Findings
| Findings in the different stages
1: Normal
2: Low voltage changing to seizure activity
3: Burst suppression to isoelectric
124
# HIE in term infants
Duration
| Findings in the different stages
1: < 24hrs if progresses, otherwise, may remain normal
2: 24hr to 14 days
3: Days to weeks
125
# HIE in term infants
Myoclonus
| Findings in the different stages
1: Present
2: Present
3: ABsent
126
# HIE in term infants
Pupils
| Findings in the 3 stages
1: Mydriasis
2: Miosis
3: Unequal, poor light reflex
127
# HIE in term infants
Seizures
| Findings in the 3 stages
1: None
2: Common
3: Decerebration
128
# HIE in term infants
EEG findings
| Findings in the 3 stages
1: Normal
2: low voltage changing to seizure activity
3: Burst suppression to isoelectric
129
Approximately 45% of brachial plexus injuries are associated with?
## Footnote
Brachial plexus (spinal root C5-T1)
Shoulder dystocia
130
The characteristic position of this peripheral nerve injury consists of adduction and internal rotation of the arm with pronation of the forearm. Power to extend the forearm is retained, but the biceps reflex is absent; the Moro reflex is absent on the affected side
Erb-Duchene paralysis (C5, C6)
131
This peripheral nerve injury produces a paralyzed hand and ipsilateral ptosis and miosis (Horner Syndrome) if the sympathetic fibers of the 1st thoracic root are also injured
Klumpke's paralysis (C7, C8)
132
# True or False
In general, paralysis of the upper part of the arm has a poorer prognosis than paralysis of the lower part.
False
133
Involvement of the deltoid is usually the most serious problem and may result in ____ 2o to muscle atrophy
shoulder drop
134
Treatment for peripheral nerve injuries.
initial conservative management with monthly follow-up and a decision for surgical intervention by 3 mo if function has not improved. Partial immobilization and appropriate positioning are used to prevent the development of contractures.
Gentle massage and range-of-motion exercises may be started by 7-10 days of age.
If the paralysis persists without improvement for 3 mo, neuroplasty, neurolysis, end-to-end anastomosis, and nerve grafting offer hope for partial recovery.
135
What is the mildest injury to the peripheral nerve called and what causes it?
**neurapraxia** is caused by edema and heals spontaneously within a few weeks
136
This is a consequence of nerve fiber disruption with an intact myelin sheath; function usually returns in a few months.
Axonotmesis
137
This must be considered when cyanosis and irregular and labored respirations develop in a neonate, the abdomen does not bulge with inspiration, and breath sounds are diminished on the affected side.
Phrenic nerve injury (3rd, 4th, 5th cervical nerves) with diaphragmatic paralysis.
138
Diagnosis of phrenic nerve paralysis is established by ____ showing what?
US or fluoroscopic examination, which reveals elevation of the diaphragm on the paralyzed side and seesaw movements of the 2 sides of the diaphragm during respiration. It may also be apparent on chest or abdominal radiograph.
139
Management of an infant with phrenic nerve injury.
Infants with phrenic nerve injury should be placed on the involved side and given oxygen if necessary. Some may benefit from pressure introduced by continuous positive airway pressure (CPAP) to expand the paralyzed hemidiaphragm. In extreme cases, mechanical ventilation cannot be avoided. If the infant fails to demonstrate spontaneous recovery in 1-2 mo, surgical plication of the diaphragm may be indicated.
140
In this nerve injury, when the infant cries, movement occurs only on the nonparalyzed side of the face, and the mouth is drawn to that side. On the affected side the forehead is smooth, the eye cannot be closed, the nasolabial fold is absent, and the corner of the mouth droops.
Peripheral facial paralysis
141
Central facial paralysis spares what part of the face?
the forehead (e.g., forehead wrinkles will still be apparent on the affected side) because the nucleus that innervates the upper face has overlapping dual innervation by corticobulbar fibers originating in bilateral cerebral hemispheres.
142
What is the most sensitive imaging modality for detecting hypoxic brain injury in the neonate?
MRI obtained in the 1st 3-5 days following a presumed sentinel event are optimal for identifying acute injury.
143
What treatment has been shown to reduce mortality and major neurode- velopmental impairment at 18 mo of age after HIE?
Therapeutic hypothermia to a core rectal or esophageal temperature of 33.5°C [92.3°F] within the 1st 6 hr after birth and maintained for 72 hr.
The therapeutic effect of hypothermia likely results from decreased secondary neuronal injury achieved by reducing rates of apoptosis and production of mediators known to be neurotoxic, including extracellular glutamate, free radicals, nitric oxide, and lactate.
144
Complications of induced hypothermia
* thrombocytopenia (usually without bleeding),
* reduced heart rate, and
* subcutaneous fat necrosis (sometimes with associated hypercalcemia)
* potential for overcooling and
* cold injury syndrome
145
1st line drug for treating seizures associated with HIE.
Phenobarbital
It is typically given by intravenous loading dose (20 mg/kg). Additional doses of 5-10 mg/kg (up to 40-50 mg/kg total) may be needed. Phenobarbital levels should be monitored 24 hr after the loading dose has been given and maintenance therapy (5 mg/kg/24 hr) begun. Therapeutic phenobarbital levels are 20-40 μg/mL.
146
Preferred drug for refractory seizures 2o to HIE?
Levetiracetam
Suggested appropriate loading doses may be closer to 60 mg/kg.
147
In term infants needing PPV, how is it given?
PPV should be initiated at pressures of approximately 20 cm H2O at a rate of 40-60 breaths/min initially with 21% fraction of inspired oxygen (FIO2)
148
What is the preferred initial gas for neonatal resuscitation in term infants?
Room air
149
# NRP
If after 30 sec of providing PPV there are no signs of effective ventilation, what are the corrective steps that should be performed to improve ventilation?
MRSOPA
*M*ask readjustment
*R*eposition the head
*S*uction mouth and nose
*O*pen the mouth
*P*ressure increase
*A*lternate airway
150
# NRP
Chest compressions should be initiated over the lower third of the sternum at a rate of ?
90/min
151
# NRP
The ratio of compressions to ventilation is ?
3:1 (90 compressions:30 breaths)
152
# NRP
If adequate resuscitation continues for ____ min without a detectable heart rate, it is reasonable to stop resuscitative efforts.
10
153
# NRP
Resuscitation of most preterm infants can be initiated with slightly higher FIO2 of?
21 - 30%
154
This procedure allows time to secure the airway in an infant known prenatally to have critical airway obstruction, before the infant is separated from the placenta.
Ex utero intrapartum treatment (EXIT)
155
What finding is suggestive of a diaphragmatic hernia in a newborwn?
Scaphoid abdomen
156
For a pneumothorax, an angiocatheter should be inserted perpendicular to the chest wall above the rib in the ____ and air evacuated.
2nd intercostal space in the midclavicular line
157
For a pleural effusion, with the infant in the supine position, the angiocatheter should be inserted in the ____ and directed posteriorly to evacuate the fluid
4th or 5th intercostal space in the anterior axillary line
158
Differentiate gastroschisis from omphalocele.
Gastroschisis is the more common defect, and typically the intestines are not covered by a membrane. The exposed intestines should be gently placed in a sterile clear plastic bag after delivery. A membrane often covers an omphalocele, and care should be taken to prevent its rupture.
159
What is the most common intracranial injury experienced at birth?
Subdural hemorrhage
160
What is the most frequently fractured bone during labor and delivery?
Clavicle
Symptoms of a clavicular fracture include an infant not moving the arm freely on the affected side, palpable crepitus or bony irregularity, and asymmetric or absent Moro reflex on the affected side. The prognosis for this fracture is excellent. Often, no specific treatment is needed. In some cases the arm and shoulder on the affected side are immobilized for comfort
161
This is characterized by brief episodes of respiratory pauses lasting 5-10 sec, followed by a burst of rapid respirations at a rate of 50-60 breaths/min for 10-15 sec. The brief interruptions in respiration are not associated with change in color or heart rate.
Periodic Breathing
162
Apnea is defined as?
cessation of breathing for a period of ≥20 sec, or a period <20 sec that is associated with a change in tone, pallor, cyanosis, or bradycardia (<80-100 beats/min)
163
Obstructive apnea is characterized by?
absence of airflow but persistent chest wall motion. Pharyngeal collapse may follow the negative airway pressures generated during inspiration, or it may result from incoordination of the tongue and other upper airway muscles involved in maintaining airway patency.
164
Describe central apnea
It is caused by decreased central nervous system (CNS) stimuli to respiratory muscles, results in both airflow and chest wall motion being absent.
165
Treatment for mild or intermittent apnea
Gentle tactile stimulation or provision of flow and/or supplemental oxygen by nasal cannula is often adequate therapy.
166
Appropriate therapy for mixed or obstructive apnea.
* Nasal continuous positive airway pressure (nCPAP, 3-5cm H2O) and
* heated humidified high-flow nasal cannula (HHHFNC, 1-4 L/min)
167
Recurrent or persistent apnea of prematurity is effectively treated with?
Methylxanthines (Theophylline, caffeine)
168
Why is caffeine preferred over theophylline?
Because of its longer half-life and lower potential for side effects (less tachycardia and feeding intolerance). In preterm infants, caffeine reduces the incidence and severity of apnea of prematurity, facilitates successful extubation from mechanical ventilation, reduces the rate of bronchopulmonary dysplasia (BPD), and improves neurodevelopmental outcomes.
Can be given PO or IV. Initial loading dose of 20 mg/kg of caffeine citrate followed 24 hr later by once-daily maintenance doses of 5 mg/kg (increased to 10 mg/kg daily as needed for persistent apnea)
| therapeutic level: 8-20 μg/mL
169
Infants born well before 28 wk GA may experience apnea and bradycardic events until ____ PMA.
44 wk
170
# True or False
Apnea of prematurity increases the risk of SIDS
**False**
* Positioning, and not prematurity, primarily influences the incidence of SIDS.
* Supine positioning on a firm sleep surface separate from the parents’ bed, promotion of breastfeeding, and pacifier use during sleep reduce the incidence of SIDS.
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172
Factors associated with increased risk for development of RDS.
* maternal diabetes,
* multiple births,
* cesarean delivery,
* precipitous delivery,
* asphyxia,
* cold stress, and
* maternal history of previously affected infants.
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Factors associated with reduced risk for development of RDS.
* chronic or pregnancy-associated hypertension,
* maternal heroin use,
* prolonged rupture of membranes, and
* antenatal corticosteroid prophylaxis.
174
Primary cause of RDS
Surfactant deficiency
175
The tip of an umbilical artery catheter should lie at ____ just above the bifurcation of the aorta or at ____.
L3-L5
T6-T10
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Because of the homogeneous nature of the lung pathology associated with RDS, a high rate ( ____ ), low tidal volume ( ____ ) strategy is generally effective.
≥60/ min
4-6 mL/kg
177
What the approach of choice for the delivery room management of a preterm neonate at risk for RDS?
Prophylactic nCPAP
178
# Dopamine or Dobutamine
In hypotensive preterm infants, which is more effective in raising blood pressure?
Dopamine
179
If hypotension is refractory to vasopressor therapy, especially in neonate < 1000g, this may be caused by what? How should it be managed?
**Transient adrenal insufficiency**
Administration of intravenous hydrocortisone at 1-2 mg/kg/dose every 6-12 hr may improve blood pressure and allow weaning of vasopressors
180
This is a clinical pulmonary syndrome that develops in the majority of extremely preterm infants and is defined by a prolonged need for respiratory support and supplemental oxygen.
Bronchopulmonary dysplasia (chronic lung disease of prematurity)
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What is consistently observed in the pathogenesis of BPD?
Pulmonary inflammation and lung injury.
Alveolar collapse (atelectrauma) as a consequence of surfactant deficiency, together with ventilator-induced phasic overdistention of the lung (volutrauma), promotes lung inflammation and injury. Supplemental oxygen produces free radicals that cannot be metabolized by the immature antioxidant systems of very-low-birthweight (VLBW) neonates and further con- tributes to the injury.
182
What is a common complication of BPD?
Pulmonary hypertension
183
How is BPD diagnosed?
BPD is diagnosed when a preterm infant requires supplemental oxygen for the 1st 28 postnatal days, and it is further classified at 36 wk PMA according to the degree of O2 supplementation (Table 122.2). Neonates receiving positive pressure support or ≥30% supplemental O2 at 36 wk PMA or at discharge (whichever occurs first) are diagnosed as having severe BPD; those requiring 22–29% supplemental O2 have moderate BPD; and those who previously required O2 supplementation for at least 28 days but are currently breathing room air have mild BPD.
184
In term infants, the ductus arteriosus is usually closed by?
72 hrs of life
185
Risk factors for delayed closer of the PDA.
hypoxia, acidosis, increased pulmonary pressure secondary to vasoconstriction, systemic hypotension, immaturity, and local release of prostaglandins (which dilate the ductus)
186
Manifestations of PDA.
(1) a hyperdynamic precordium, bounding peripheral pulses, wide pulse pressure, and a machine-like continuous or systolic murmur;
(2) radiographic evidence of cardio- megaly and increased pulmonary vascular markings;
(3) hepatomegaly;
(4) increasing oxygen dependence;
(5) carbon dioxide retention; and
(6) renal failure.
187
General contraindications for COX inhibitors use for pharmacologic closure of PDA?
* thrombocytopenia (< 50,000 platelets/mm3),
* active hemorrhage (including severe IVH),
* NEC or isolated intestinal perforation,
* elevated plasma creatinine (> 1.8 mg/dL), or oliguria (urine output < 1 mL/kg/hr).
*Importantly, the concomitant use of hydrocortisone and indomethacin in extremely preterm infants must be avoided, because the combination is associated with a dramatic increase in spontaneous intestinal perforation.*
188
Which COX inhibitor is associated with reduced rates of oliguria and a small but significant reduction in the length of mechanical ventilation?
Ibuprofen
typical IV or enteral dosing regimen for ibuprofen is 10 mg/kg for 1 dose, followed by 2 doses of 5 mg/kg every 24 hr
Compared to the IV route, enteral ibuprofen may be more efficacious.
189
This syndrome can occur 6-12hrs after surgical ligation of a PDA
**Postligation cardiac syndrome** a significant drop in blood pressure 6-12 hr after ductal ligation, is experienced by up to 50% of LBW infants. The hypotension has been attributed to increased systemic vascular resistance along with decreased pulmonary venous return, resulting in impaired preload and LV function. Fluid resuscitation, inotropic support (with dobutamine or milrinone), and hydrocortisone are usually effective.
190
Distinctive features of transient tachypnea of the newborn.
The distinctive features of TTN are rapid recovery of the infant and the absence of radiographic findings for RDS (low lung volumes, diffuse reticulogranular pattern, air bronchograms) and other lung disorders.
In TTN, the chest generally sounds clear without crackles or wheeze, and the chest radiograph shows prominent perihilar pulmonary vascular mark- ings, fluid in the intralobar fissures, and rarely small pleural effusions.
191
Probable pathophysiology of TTN.
TTN is believed to result from ineffective expression or activity of ENaC and Na+,K+-ATPase, which slows absorption of fetal lung fluid and results in decreased pulmonary compliance and impeded gas exchange.
Inhaled β2-agonists such as albuterol (salbutamol) increase expression and activation of ENaC and Na+,K+-ATPase and facilitate fluid clearance. Emerging evidence suggests that when given early in the course of TTN, albuterol may improve oxygenation, shorten the duration of supplemental O2 therapy, and expedite recovery.
192
Typical CXR finding in Meconium Aspiration Syndrome (MAS)
patchy infiltrates, coarse streaking of both lung fields, increased anteroposterior diameter, and flattening of the diaphragm.
193
Patients with MAS refractory to conventional mechanical ventilation may benefit from ?
| 2
HFV or ECMO
194
Increased in pulmonary vascular resistance in the newborn may be due to?
| 4
(1) maladaptive from an acute injury (not demonstrating normal vasodilation in response to increased O2 and other changes after birth); (2) the result of increased pulmonary artery medial muscle thickness and extension of smooth muscle layers into the usually nonmuscular, more peripheral pulmonary arterioles in response to chronic fetal hypoxia; (3) a consequence of pulmonary hypoplasia (diaphragmatic hernia, Potter syndrome); or (4) obstructive as a result of polycythemia, total anomalous pulmonary venous return (TAPVR), or congenital diffuse development disorders of acinar lung development.
195
# In PPHN
Intracardiac shunting through the ____ does not lead to a PaO2 or SaO2 gradient.
**patent foramen ovale.**
A PaO2 or SaO2 gradient between a preductal (right radial artery) and a postductal (umbilical artery) site of blood sampling suggests right-to-left shunting through the ductus arteriosus.
196
Infants with this autosomal recessive disorder present with idiopathic PPHN, demonstrating little or no parenchymal lung disease and profound hypoxemia.
Alveolocapillary dysplasia (ACD) is a rare, highly lethal disorder of distal lung development characterized by immature lobular development and reduced capillary density.
Lung transplantation remains the sole, experimental therapy.
197
Treatment for PPHN?
Therapy for PPHN is directed toward correcting any predisposing condition (e.g., hypoglycemia, polycythemia) and improving poor tissue oxygenation. [iNO, ECMO]
198
Use of this agent for tx of PPHN educes the need for ECMO support by approximately 40%.
Inhaled NO.
The optimal starting dose is 20 ppm. The infant can be weaned to 5 ppm after 6-24 hr of therapy. The dose can then be reduced slowly and discontinued when FIO2 is < 0.6 and the iNO dose is 1 ppm. Abrupt discontinuation should be avoided because it may cause rebound pulmonary hypertension. iNO should be used only at institutions that offer ECMO support or have the capability of transporting an infant on iNO therapy if a referral for ECMO is necessary.
199
A major limiting factor for survival in patients with congenital diaphragmatic hernia.
associated pulmonary hypoplasia
200
# True or False
Group B streptococcal sepsis has been associated with delayed onset of symptoms and a CDH.
True (often on the right side)
201
3 main strategies to support respiratory failure in the newborn with CDH.
* **Conventional mechanical ventilation**,
* **High-frequency oscillatory ventilation (HFOV)**, and
* **ECMO**
The goal is to maintain oxygenation and CO2 elimination without inducing volutrauma. Conventional ventilation using a gentle, lung protective strategy (PIP < 25, PEEP 3-5 cm H2O) that allows for permissive hypercapnia (PaCO2 < 65-70 mm Hg) is recommended.
202
Failure of the sternal and crural portions of the diaphragm to meet and fuse produces ?
the **foramen of Morgagni hernia**
Most children with these defects are asymptomatic and are diagnosed beyond the neonatal period, often by chest radiograph performed for evaluation of another condition.
203
This is an abnormal elevation consisting of a thinned diaphragmatic muscle that causes elevation of the entire hemidiaphragm or more often the anterior aspect of the hemidiaphragm.
Eventration of the diaphragm.
This elevation produces a paradoxical motion of the affected hemidiaphragm
204
Presence of this in a newborn infant is almost pathognomonic of pneumomediastinum.
Subcutaneous emphysema
205
What is the source of blood in many cases of pulmonary hemorrhage and is associated with significant ductal shunting and high pulmonary blood flow or severe left-sided heart failure resulting from hypoxia?
Hemorrhagic pulmonary edema
206
What is the only severe complication in which the rate is increased with surfactant treatment?
Pulmonary hemorrhage.
Incidence is higher with natural surfactant.
207
Treatment of pulmonary hemorrhage.
Blood replacement, suctioning to clear the airway, intratracheal administration of epinephrine, and tamponade with increased mean airway pressure (often requiring HFV). Although surfactant treatment has been associated with the development of pulmonary hemorrhage, administration of exogenous surfactant after the bleeding has occurred can improve lung compliance, because the presence of intraalveolar blood and protein can inactivate surfactant.
