Perinatal and neonatal medicine Flashcards
Rubella in pregnancy
Notify health protection unit (HPU) HPU may want to test B19 NO effective Mx Recommend rest, fluids and paracetamol Stay off work, avoid contact w/other pregnant women after developing rash Refer to obst. for risk
CMV in the neonate Drug Mx
IV ganciclovir/ PO valganciclovir
Toxoplasmosis in neonate Mx
1st line: pyrimethamine + sulfadiazine + Ca folinate
adjunct: pred
Newborn Hearing Screening
EOAR: Earphone over ear plays sound which causes echo if cochlear function is normal (if normal not achieved move onto:)
AABR: computer analyses EEG waveforms evoked by series of clicks
Neonatal nerve palsies
Most will resolve completely
Resp. distress syndrome
Oxygen and ventilation
CPAP or AV via tracheal tube possible
other: high flow hum. 02, mechanical v.,
Exogenous surfactant via ET tube
Neonatal pneumothorax
Immediate decompression + O2 + chest drain if tension
Neonatal PDA
Closed using: IV indomethacin, prostacyclin synthase inhibitor, ibuprofen
If fail: surgical ligation or percutaneous catheter device closure
Necrotising Enterocolitis
Ix: AXR, cultures
Stop oral feed
broad spec Abx (ceotaxine/vancomycin)
If perf/necrosis: surgery
Parenteral nutrition always required, often ventilatory/circulatory support
long term Cx: strictures, malabs. if resection
Neonatal jaundice Ix
Haematocrit Blood group of mother and baby DAT (+did mother receive aniti-D?) FBC and film (spherocytes) Blood G6PD levels Culture blood, urine, CSF if ?infection TSH LFTs Bili
Assessment of Neonatal jaundice
Visually assess baby in light
Measure bilirubin:
- Serum: If jaundice within 24hrs of birth or GA <35w
- Transcutaneous: GA >35w or jaundice >24hrs of life (if >250umol check serum bili)
Check bili 6hrly until below threshold or becomes stable/falling
Risk of developing Kernicterus
increased risk if
serum bili >340umol in >37w GA
Rising >8.5umol/hr
Fx of bilirubin encephalopathy: poor feed, lethargy, hypotonia
Mx of neonatal jaundice
Threshold table:
- No Mx
- Phototherapy (+/- IVIG)
- Exchange transfusion
If baby clinically well, GA >38 and >24hrs old w/bili within 50 of phototherapy threshold:
- repeat 18hrs for any RiskFactors , 24hrs for no RF baies
Phototherapy in Neonatal jaundice
450nm (green-blue)
Photobilirubin and lumirubin
Dont need conj. -> excreted
Can stop once >50umol below Rx threshold
Monitoring in neonatal phototherapy
Serum bili 4-6hrly Monitor temp protect eyes encourage short bf breaks (<30m) Check for rebound hyperbili at 12-18hrs
Indications for intensive phototherapy
- bili >8.5umol inc. /hr
- within 50umol of threshold for exchange trx >72hrs from birth
- Bili doesnt respond witihin 6hrs
- reduce intensity once bili >50 from exchange trx threshold
Other option for neonatal jaundice
IVIG - adjunct in cases of RhHDN, ABO HDN, or if serdum bili >8.5umol/hr
Exchange Trx: Above threshold OR if Sx of bili encephalopathy Double-volume exchange used in babies during trx do NOT stop phototherapy Measure serum bili within 2hrs
PACES counselling of Neonatal jaundice
Explain is common: if: <1d, >14d will Ix cause Physiological often Mx: light therapy - not harmful but eyes protected and regular bloods - bf can continue - need to stay in for another blood at 12-18h Resources: NHS choices Neonatal jaundice Bf network Bliss (prem/sick babies)
Meconium Ileus
gastrograffin enema (n-acetylcysteine and option too) Sx if ineffective
Meconium aspiration
Ix: CXR (?pneumomediastinum), FBC+CRP, culture
If normal term infant w/mec stained amniotic fluid but NO Hx of GBS observe
If any risk factors or lab findings suggestive of infection consider Abx: ampicillin + gent
In sev cases: O2 and CPAP
Persistent pHTN of neonate
CXR: normal heart but pulmonary oligaemia Urgent echo to rule out CHD Mx: Mec. vent+circ support Inhaled NO (vasodilator) Sildenafil ?Oscillatory vent. Sev. but reversible; extracorporeal membrane oxygenation
Congenital diaphragmatic hernia
Once Dx large NG tube passed and suction applied to present distension of intrathoracic bowel
req. surg
Early onset sepsis (<72hr) Ix
FBC U+E CRP Cultures Urine dip and MSU LP (ALL infants <1m, 1-3 appear unwell or WCC <5 or >15, (or if FNS/blood culture +ve req. examination and culture)) CXR
Early onset sepsis Abx
Immediate no wait for results
IV should cover:
GBS, listeria, other G+, G-
e.g. Benzylpenicillin/amoxicillin + gentamicin
If CRP -ve and infant well Abx can be stopped after 48hrs
Late onset sepsis >72hrs pathogens
Most common: coagulase -ve staph (epidermis)
others:
G+: S aureus, E faecalis
G-: klebsiella, pseudomonas
Late onset sepsis (>72hrs) Abx
Ampicillin + gent/cefotaxime Vanc + gent ?sensitivities Vanc for coag. -ve Staph. if all else fails mero NB long term broad spec ABx risks invasive fungal infection
Neonatal meningitis
Uncommon but high mort and morb 1/3 maj. sequele
late Sx: bulging fontanelle, opisthotonos
Mx: ampicillin + 3rd gen ceph. (cefotaxime)
Cx: cerebral abcesss
Paediatric sepsis 6
- O2
- IV access (cultures, glucose, A/C/V gases)
- IV broad spec Abx
- IV fluids
- Senior clinicians involved early
- Vasoactive intropic support considered early
(if normal parameters not achieved after 40ml/kf resus
GBS neontate
Benzylpenicillin or ampicillin
AND
Gent./cefotaxime/ceftriaxone
supportive
Listeria monocytogenes neonate
amox. co-trimoxazole
NB. trimethoprim CI in preg
if systemic: IV benpen+Gent
Conjunctivitis in the neonate
Clear w/water/saline in most cases
Neomycin for staph/strep Sx
Gonococcal infection: sample, stain, culture the discharge (Mx: 3rd gen ceph.)
Chlamydia: PO erythromycin 2w
Best practice:
opthalmic azithromycin/erythromycin
antihistamines/artificial tears for viral conjunctivitis
Herpes simplex in neonate
If mother has primary dx or genital lesions within 6weeks of del. then c-sec
If earlier PO aciclovir from 36w
Aciclovir can be given to baby during risk period
HBV in neonate
infants of HBsAg+ mothers receive vaccination after birth (birth,1m,6m) and HBV IG
Mothers: antiviral monotherapy tenofovir or lamivudine
Neonatal hypoglycaemia
Prevented by early and freq feed
Glucose IV if severe
Glucagon and hydrocortisone too if you like
Aim for glucose >2mmol/L
Cleft lip/palate
Specialised feeding may be req.
?airway problems (e.g. Pierre RObin)
Pre-surgical lip tapping, oral appliances, PNAM may narrow cleft
Definitive Mx: surgery
