Peri and neonatal Medicine Flashcards
What can opioid analgesics use during labour do?
May suppress respiration at birth
Effect of epidural anaesthesia during labour?
Can cause maternal pyrexia which is often difficult to differentiate from fever caused by infection
What can oxytocin and prostaglandin use during labour do?
Can cause hyperstimulation of the uterus leading to fetal hypoxia
What is transient tachypnoea of the new born and when can it occur?
Rapid, laboured breathing for several hours after birth by c-section
Because lungs weren’t squeezed during delivery therefore fluid was not squeezed out and there is still fluid in lungs
What does Apgar score measure?
Used to measure babys condition 1 and 5 mins after delivery and then every 5 mins afterwards if condition remains poor
What measurements are included in Apgar score?
Heart Rate >100 bpm = good Respiratory effort Muscle tone (flexion good) Reflex irritability (grimace (1) or cry (2)) Colour (pink good)
When does passage of meconium become more common
Greater the infants gestational age, especially post-term
What can happen with passage of meconium?
If infants become acidotic from aspyhxia and try to breathe in utero then they can inhale thick meconium and develop meconium aspiration syndrome
Risk with aspiration of newborn and management
Can stimulate reflex bradycardia and cause newborn to be bradycardic
If regular breathing starts then nothing, if doesn’t - aspiration and if bradycardic then Post-pressure ventilation
Way to manage respiratory depression following maternal opiate use
Give Naloxone if respiration continues to be depressed following initial resuscitation
Phases of neonatal resus
Airway opening maneouvres Mask ventilation Two-person airway control Tracheal intubation Reintubate Chest compressions if HR
Resus of pre-term infants
Placed in a plastic bag or wrapped in plastic sheeting with exception of face
Use air/oxygen mixer to prevent excessive tissue oxygenation
What is erythema toxicum?
Neonatal urticaria
A common rash appearing at 2-3 days of age
Consisting of white pinpoint papules at the centre of an erythematous base
Fluid contains eosinophils
Mostly on the trunk - come and go at different sites
What is Mongolian blue spots
Blue/black macular discolouration at base of the spine and on buttocks
Usually but not invariably in Afro-Caribbean or Asian infants
Fade slowly over first few years
What is port-wine stain
Naevus flammeus
Due to vascular malformation of capillaries in dermis
Present from birth and usually grows with the infant
What can port-wine stain be associated with if in trigeminal nerve distribution?
Associated with intracranial vascular anomalies = Sturge-Weber syndrome
What are strawberry naevus?
Cavernous haemangioma
Not present at birth but appear in first month of life and may be multiple
More common in preterm
Development of strawberry naevus?
Increases in size until 3-15 months old
Then gradually regresses
Management of strawberry naevus
No treatment needed unless vision or airway are obstructed
Thrombocytopenia may occur with large lesions - therapy with systemic steroids or interferon-a may be required
Heart murmurs in newborn?
Most murmurs audible in first few days of life resolve shortly afterwards
Some are caused by congenital heart disease and if there is a significant murmur then investigation is needed
Vit K and newborn
Should be given to all newborns to prevent haemorrhagic disease of the newborn
At risk infants (mothers on anticonvulsant therapy) should be given IM
IM better than orally but controversial
What is screened for with the Guthrie test? x5
Phenylketonuria Hypothyroidism Haemoglobinopathies Cystic fibrosis MCAD deficiency
When is Guthrie done?
Day 5-9 of life when feeding has been established
How is cystic fibrosis detected?
Serum immunoreactive trypsin - raised if there is a pancreatic duct obstruction
What is hypoxic-ischaemic encephalopathy?
Brain damage following perinatal asphyxia and diminished brain tissue perfusion
Causes of hypoxic-ischaemic encephalopathy? x5
Failure of gas exchange across placenta
Interruption of umbilical blood flow (cord compression)
Inadequate maternal placental perfusion
Compromised fetus (anaemia, IUGR)
Failure of cardiorespiratory adaptation at birth
Clinical features of mild HIE x5
Irritable infant, responds excessively to stimulation
May have staring of eyes and hyperventilation
Impaired feeding
Moderate HIE features x3
Infant shows marked abnormalities of tone and movement
Cannot feed
May have seizures
Severe HIE features x4
No normal spontaneous movements or response to pain
Limb tone may fluctuate between hypotonia and hypertonia
Seizures prolonged and often refractory to treatment
Multi-organ failure
Management of HIE
Monitoring
Respiratory support
Electrolyte balance
Restrict fluids as transient renal impairment
Treat any seizures with anticonvulsants
(wrapping in cooling blanket may help reduce brain damage - induced mild hypothermia)
Prognosis of HIE
Mild can recovery completely
Moderate if recovery and neuro exam/feeding normal at 2 weeks then good prognosis, but if clinical abnormalities persist beyond 2 weeks - unlikely to improve
Severe = mortality of 30-40% and over 80% over survivors have neurodevelopmental disabilities
Severe consequence of HIE
Cerebral palsy
What is Chignon?
Oedema and bruising from Ventouse
What is Caput Succedaneum?
Birth injury causing bruising and oedema of presenting part extending beyond margins of skull bones
resolves in few days
What is Cephalhaematoma
Birth injury
Haematoma from bleeding below periosteum, confined within margins of skull sutures
Usually over parietal bone and centre feels soft
Resolves over several weeks
When do brachial nerve palsys occur in delivery
May occur at breech deliveries or with shoulder dystocia
Upper nerve root brachial plexus injury name and association
Erb Palsy
May also be associated with phrenic nerve injury causing elevated diaphragm
Erb palsy management
Most resolve completely but should be referred to orthopaedic surgeon if not resolved within 2-3 months
What is common cause of clavicle or humerus/femur fracture in delivery
Shoulder dystocia (femur - breech deliveries) Both heel rapidly and well
What is respiratory distress syndrome?
Due to deficiency of surfactant in preterm babies
Alveolar collapse and inadequate gas exchange
Treatment of RDS
Surfactant therapy
Ventilation
RDS on chest xray x3
Diffuse granular or ‘ground glass’ appearance of lungs
Air bronchogram - larger airways outlined
Heart border indistinct or obscured with severe disease
What can develop with RDS
Pneumothorax
From ventilation of RDS
Thorax will transilluminate
Other pre-term concerns
Keep warm
Fluid increase
Increased nutrition (supplementations in milk with phosphate, protein, calories, calcium, vitamin D, iron)
Patent ductus arteriosus
Risk with preterm infants
Risk of infection
Maternal IgG is transferred in last trimester
Therefore increased risk of infection compared to term babies
What is preterm brain injury?
Haemorrhages in the brain occur in 25% of very low birth weight babies
Most within first 72 hours of life
More common if asphyxia or RDS
What happens to eyes of preterms?
Retinopathy of prematurity
affects developing blood vessels causing vascular proliferation which may progress to retinal detachment, fibrosis and blindness
Why do 50% of newborns become jaundice?
Marked physiological release of Hb from breakdown of RBCs because of high Hb concentration at birth
RBC life span of newborns is less - 70days
Hepatic bilirubin metabolism is less efficient in first few days of life
What is Kernicterus?
Encephalopathy resulting from deposition of unconjugated bilirubin in basal ganglia and brainstem nuclei - may occur when level of unconjugated bilirubin exceeds albumin binding capacity of bilirubin in the blood
Acute manifestations of kernicterus?
Lethargy and poor feeding
More severe - irritability and increased muscle tone, seizures and coma
What happens to infants that survive having Kernicterus? x3
Choreoathetoid (chorea + athetosis - twisting and writhing) cerebral palsy, learning difficulties and sensorineural deafness
What did Kernicterus used to be common with?
Rhesus haemolytic disease - now less common with anti-D
Causes of non-physiological jaundice
Haemolytic disease - rhesus or ABO incompatibility
G6PD deficiency
Spherocytosis
Congenital infection
Causes of jaundice at 1 day - 2 weeks
Physiological Breast milk jaundice Dehydration (delay in establishing breast feeding) Infection Crigler-Najjar
Causes of conjugated jaundice >2 weeks age
Bile duct obstruction - biliary atresia
Neonatal hepatitis
Management of unconjugated jaundice
Phototherapy
Exchange transfusions if levels are dangerous
Causes of unconjugated jaundice >2 weeks age
Breast milk jaundice
Infection (esp. urinary tract)
Congenital hypothyroidism
Signs of conjugated jaundice aka biliary atresia
Dark urine and pale stools
Hepatomegaly, poor weight gain
Features of diaphragmatic hernia
Usually left-sided herniation of abdominal contents through posterolateral foramen of diaphragm
Apex beat and heart sounds displaced to right and poor air entry in left chest
Respiratory distress will be present
Surgically treated - main complication is pulmonary hypoplasia
When is risk highest in childhood for developing a serious invasive bacterial infection
Neonatal period
What is early-onset sepsis?
Sepsis which occurs within 48hours of birth
What causes early-onset sepsis?
Bacteria have ascended from birth canal and invaded amniotic fluid - fetus then infected because fetal lungs are in direct contact with infected amniotic fluid
Type of infection in early-onset sepsis?
Infants have pneumonia and secondary bacteraemia/septicaemia
What increases the risk of early-onset sepsis? x2
Prolonged or premature rupture of amniotic membranes
Maternal fever during labour due to chorioamnionitis
Presentation of early-onset sepsis? x3
Respiratory distress, apnoea and temperature instability
Diagnosis of early-onset sepsis? x4
Chest X-Ray
Septic screen
FBC for neutropenia
Blood cultures
Treatment of early-onset sepsis?
IV antibiotics started immediately - usually benzylpenicillin or amoxicillin (for group B strep, listeria and other gram positive) as well as gentamicin (for gram negative organisms)
What is late-onset infection
Infection >48h after birth
Source of infection with late-onset infection?
Usually in the infant’s environment
Presentation of late-onset infection
Usually non-specific - fever/temp, not feeding, vomiting, resp. distress, jaundice etc
Most common pathogen in neonatal intensive care
Coagulase negative staphylococcus - staph epidermis
Treatment of late-onset infection
Flucloxacillin and gentamicin - to cover most staphylococci and gram-negative bacteria
Treatment of neonatal sticky eyes
Cleaning with saline or water and it will resolve spontaneously
Other more serious causes of conjunctivitis in neonatal period
Redness and discharge could be staphylococcal or streptococcal - treat with antibiotic eye ointment eg. neomycin
Purulent discharge and eyelid swelling could be gonococcal
Also could be chlamydial
HSV neonatal infection presentation
Any time up to 4 weeks of age
Local herpetic lesions on skin or eye
or as encephalitis and disseminated disease
Treatment of neonatal HSV
Aciclovir
Management of infants born to hep B surface-antigen positive mothers
Should receive Hep B vaccination after birth and complete course during infancy
Who is hypoglycaemia common in, in first 24h of life x7
Babies with IUGR, born preterm, born to mothers with DM, large-for-dates, hypothermic, polycythaemic or ill
Cause of hypoglycaemia in IUGR or preterm infant
Poor glycogen stores
Cause of hypoglycaemia in baby born to diabetic mother
Have sufficient glycogen stores but hyperplasia of islet cells in pancreas cause high insulin levels
Symptoms of neonatal hypoglycaemia
Jitteriness, irritability, apnoea, lethargy, drowsiness and seizures
Management of neonatal hypoglycaemia
Can usually be prevented with early and frequent milk feeding
If two low values or one v.low value recorded then give IV infusion of glucose
Cause of cleft lip
Failure of fusion of frontonasal and maxillary processes - can be unilateral or bilateral
Cause of cleft palate
Failure of fusion of palatine processes and nasal septum
Management of cleft lip and cleft palate
Surgical repair - can be done of lip within first few weeks of life but palate usually done at several months
What are cleft palate patients prone to?
Secretory and acute otitis media
What is oesophageal atresia associated with?
Tracheo-oesophageal fistula and associated with polyhydramnios during pregnancy
Clinical presentation of oesophageal atresia
Persistent salivation and drooling from the mouth after birth
If not detected will choke when fed and have cyanotic episodes
What is exomphalos?
Also omphalocele
Protrusion of abdominal contents through the umbilical ring, covered with transparent sac
What is gastroschisis
Bowel protrudes through defect in anterior abdominal wall, adjacent to umbilicus and no covering sac
Associations of exomphalos and gastroschisis?
Exomphalos is associated with other congenital abnormalities but gastroschisis is not
Clinical signs of RDS x4
Tachypnoea >60 breaths/min
Laboured breathing with chest wall recession and nasal flaring
Expiratory grunting
Cyanosis if severe
What is Sturge-Weber syndrome?
Encephalotrigeminal angiomatosis - port wine stains, glaucoma, seizures, mental retardation and ipsilateral leptomeningeal angioma
