Perinatal + Neonatal issues Flashcards
What do you use the Apgar score for?
Helps ID infants needing resuscitation
Also helpful to evaluate resuscitation efforts
How often give Apgar scores?
1 min
5 min
every 5 min after
Which Apgar scores need resuscitation?
0-3 at 1 min
Birth injuries
Avoidable and unavoidable injuries during L&D
Cephalhematoma Caput succedaneum SubQ fat necrosis Brachial palsy Facial palsy Clavicular fx Subconj hemorrhage
Cephalhematoma
SubPERIOSTEAL bleed
DOES NOT cross suture lines
- b/c limited to bone
Can feel rim around edge
Resolve spontaneously over several months
Common cause of jaundice
Caput succedaneum
Swelling of scalp 2/2 pressure exerted on that part during L&D
CROSSES suture lines
Resolves in a few days
Subcutaneous fat necrosis
Hx of difficult L&D
Rubbery, firm nodules on cheeks or buttocks and extremities
Usually resolve –> but can become calcium deposits in lesions
Clavicular fx - tx?
Tx not needed
Will feel crepitus over fx
Asymmetric moro
Coloboma
a hole in one of the structures of the eye, such as the iris, retina, choroid, or optic disc.
caused when a gap called the choroid fissure, which is present during early stages of prenatal development, fails to close up completely before a child is born
Aniridia
Absence of iris
assoc w/
- hemihypertrophy –> Wilms tumor
Hemihypertrophy + Aniridia –> what is going on?
Wilms tumor
Branchial cleft cyst
failure of obliteration of the second branchial cleft (or failure of fusion of the second and third branchial arches)
Usually unilateral
Can become infected
Congenital torticollis
Twisted neck
2/2 Injury to SCM during delivery
Tx muscular torticolis with stretching exercises
Breast hypertrophy
In neonate, 2/2 increased circ hormones
Supernumerary nipples (polythelia)
Occur along mammary line
Assoc w/ renal and cardiovascular anomalies
Poland syndrome
Amastia
Pectoalis muscle aplasia
Rib deformities
Webbed fingers
Radial nerve aplasia
Pectus excavatum
Usually benign
Surgery for cosmetic reasons
Pectus carinatum
Pigeon chest
Usually benign
Surgery for cosmetic reasons
Most abdominal masses in newborn 2/2
Renal
- hydronephrosis
- PCKD
Umbilical hernias
incomplete closure of fascia of umbilical ring
Assoc w/ diastasis recti (disorder defined as a separation of the rectus abdominis muscle into right and left halves)
Usually close spontaneously by 1 yo
Surgery if persists until 3-4yo, > 2cm, causes sx, or enlarges after age 1-2years
Omphalocele
Herniation of peritoneum + abdominal contents into umbilical cord
Wrap bowel with sterile saline dressings + plastic wrap
Insert orogastric tube to decompress stomach
Est IV access
Surgery ASAP
Gastroschisis
Hernation w/o sac through abdominal wall defect to RIGHT SIDE of umbilical cord
Wrap bowel with sterile saline dressings + plastic wrap
Insert orogastric tube to decompress stomach
Est IV access
Broad spectrum Abx
Then Surgery ASAP
Epispadia vs Hypospadia
Epispadia - open on dorsum of shaft of penis (pee into eye)
Hypospaida = opening on ventral side of shaft of penis
- avoid circumcision so can repair with foreskin
- ventral hood seen
- chordee sometimes associated
When fix undescended testes?
If not descended by 1 year
Surgery to avoid sterility or malignant degeneration
When fix retractile testes?
Don’t need to! It’s just an overactive cermasteric reflex
Hydrocele
Collection of fluid in scrotum (tunica vaginalis)
Usually resolves by 1 yr –> if not –> surgery
Dx w/ transillumination
Most common hernias in kids
Inguinal (indirect)
Presentation of infants born to Diabetic mothers
Ruddy plethoric complexion
Large for gestation age
Hypocalcemia
Hypomagnesemia
Insulin —| surfactant
- prone to respiratory distress
Hypertrophic cardiomyopathy
Hyperbilirubinemia
Polycythemia
Heart defects
- ASD
- VSD
- transposition
- asymmetric septal hypertrophy
Tx infants of diabetic mothers
Control mom’s blood sugar
monitor baby, tx hypoglycemia aggressively
What is counted as small for gestational age/IUGR?
Birth wts below 3rd percentile for calculated gestational age
Symmetric (if all ht, wt, etc small) vs asymmetric (if only one part of body is small)
Factors affecting growth of fetus
Fetal
- chromosomal DO
- TORCH infections
- congenital anomalies
- insulin deficiency
Placental
- infarction
- separation
- twin twin transfusion
Maternal
- toxemia
- HTN
- malnutrition
- smoking
- EtOH
Which scoring system helps determine gestational age using physical and neuromuscular criteria?
Ballard scoring system
Onset of WD in babies for
- heroin
- methadone
- phenobarbital
Heroin = 48 hrs after birth
Methadone = several wks (higher risk seizures)
Phenobarbital = 1-2 weeks
Respiratory distress syndrome
- presentation
- CXR
Tachypnea
Nasal flaring
Retractions
Cyanosis
Condition peaks at 3rd day
CXR
- reticular granular pattern
- air bronchograms
Tx RDS
- full term baby
- steroids 48 h before delivery
Transient tachypnea of newborn (TTN)
Self limited
Mostly in babies after C section
O2 requirement minimal
CXR = fluid in fissure and prominent vascular markings
2/2 retained fetal lung gluid
Meconium aspiration syndrome
Tachypnea + hypoxia
CXR = patchy infiltrates
PTX common finding
Tx - mech ventilation, NO, extracorporeal membrane oxygenation
Persistent fetal circulation
Severe hypoxemia –> pulm vasoconstrict –> R to L shunting through PFO or PDA
Echo = increased pulm A pressures, shunting
Tx
- hyperventilation to avoid acidosis
- maintain O2
- NO
- ECMO
Diaphragmatic hernia
Ab contents into cehst –> pulmonary hypoplasia
Scaphoid abdomen _ respiratory distress
Surgery to correct
Neonatal jaundice 2/2
Unconj bilirubin deposits in skin
Physiologic jaundice vs pathologic jaundice vs breast milk jaundice
Physio
- after day 1
- 12.9-15 mg/dL unconj
- resolves 1 wk
Anything else outside of this is pathological
Breast milk
- present at 1 wk
Tx neonatal jaundice
Phototherapy
- isomerizes unconj bilirubin to form more easily excreted
Exchange transfusion
- remove bilirubin
- remove circulating Abs to Hgb
Complications of neonatal jaundice
Unconj:
- Neurotoxicity
- Kernicterus (bilirubin accumulate in gray matter)
Cause neonatal sepsis
Risk factors
Group B strep (#1)
Ecoli
Listeria
UTI
Chorioamniotiis
Prematurity
Prolonged rupture of membranes
Signs of neonatal sepsis
May not always have fever
Full fontanel palpated on PE
Intrapartum antimicrobial ppx if…
+ GBS at 3-37 wks
OR
Prev infant w/ invasive dz GBS bacteruria during preggers Prematuirty Rupture of membranes > 18 h Intrapartum temp > 38 C Unknown GBS status
Tracheoesophageal fistula
85% are atretic + fistula between trachea + distal esophagus
Coughing / choking w/ swallowing
Polyhydramnios
Higher risk congenital heart dz (PDA, coarctation of aorta)
VACTERL association
- vertebrae
- anus
- cardio
- trachea
- esophagus
- renal
- limb buds
Duodenal atresia
Bilious vomiting w/ feeding
Double bubble on abdominal films
Higher risk in Trisomy 21
Tx surgery
Hirschsprung disease
Suspect in any newborn fail to pass meconium in 1st 24-48 hrs life
Absence of ganglion cells
Gold st dx - bx rectal mucosa –> no ganglion cell
Tx surgery
Necrotizing enterocolitis
1 surgical + medical GI emergency in newborn
Related to introduction of feeds
Bloody stools
Apnea
Lethargy
Pneumatosis intestinalis on Xray pathognomonic
Tx
- medical –> stop feeds, decompress, supportive
- surgery if necrotic bowel
Why are tonic clonic seizures uncommon in neonates?
b/c immaturity of NS
1 cause neonatal seizures
Hypoxic ischemic encephalopathy
12-24 hr present
More common cause of seizures in premies
Intraventricular hemorrhage
- occurs 1-3 days age
Maternal dz affecting baby:
- cyanotic heart dz
- hyperparathyroidism
- SLE
Cyanotic heart dz –> intrauterine growth retardation
Hyper PTH –> HYPOcalcemia
SLE –> congenital heart block
Maternal drugs affecting neonate
- phenobarbital
- sulfonamides
Phenobarbital –> vit K deficiency
Sulfas –> displace bilirubin from albumin
Maternal intake affecting babies:
- EtOH
- isotretinoin
- phenytoin
- stilbestrol
- tetracycline
EtOH –> FAS
Isotretinoin
- facial, ear anomalies
- congenital heart dz
Phenytoin
- hypoplastic nails
- typical facies
- IUGR
Stilbestrol
- vaginal adenocarcionma
Tetracycline
- enamel hypoplasia
Sequence of resuscitation in neonate
Position ,suction, tactile stimulation
O2
Bag valve ventilation
Chest compression
Intubation
Meds
How old can you be to get heimlich?
> 1 yo
< 1 yo = back blows + chest thrusts
NO BLIND FINGER SWEEPS
Immunological factors in breasmilk
IgA
Lactoglobulin
Maternal macrophages
Contraindications to breastfeeding
Active or untreated TB (can start MF 2 wks after anti-TB tx)
HIV
Syphilis
Galactosemia
Varicella < 5d earlier or 2 d after delivery
Herpes if active lesions on breast
Drugs - EtOH, nicotine, antineoplastics, ergot alkaloids, Lithium, cyclosporine, street drugs
Mastitis is OK
INFANT galactosemia
Cons of whole milk
Higher renal solute load –> damaging
Can provoke intolerance of whole milk protein
Increase incidence of Fe deficiency anemia
What should you supplement with in kids drinking goat milk?
Folate
Milk or soy protein induced proctocolitis
Exclusive to infants
Presents at 2-8 wks
Non-IgE mediated immuno response to dairy and/or soy proteins
Severe reflux or vomiting
+/- Painless bloody stools
+/-Eczema
Dx/Tx
- elim milk/soy from diet in mom of breastfed infants
- hydrolyzed formula in formula fed
Spontaneous resolution by year 1
Clubfoot (talipes equinovarus)
Equinus + varus of calcaneum and talus
varus of midfoot
Adduction of forefoot
Tx
- nonsurgical: stretch + manipulate foot, serial plaster casts
- Start ASAP
- surgery if no good results between 3-6 mo old, definitely < 12 mo
DDX:
- metatarsus adductus
- tibial torsion
- femoral anteversion
1 cause congenital aplastic anemia
Fanconi anemia
Race tending to have above average birth weights
African american boys
Risk factors for fetal macrosomia
Wt > 4kg
Maternal
- advanced age
- diabetes
- excessive wt gain during preggers
- preexisting obesity
- multiparity
Fetal
- AA or hispanic
- male baby
- post term
Recommend csection for suspected fetal macrosomia?
No
Rate of shoulder dystocia is not different with csection and vaginal
Intraventricular hemorrhage
Bleeding in germinal matrix
Grades 1-4 (3 and 4 have most long term sequelae)
Mostly in:
- premature
- LBW infants
Sx:
- seizures
- cyanosis
- bulging or tense fontanel
- apnea, bradycardia
Ppx:
- transfontanel ultrasound for all newborns with predisposing risk factors
Hyaline membrane disease
Usually in preemies
2/2 decreased production and secretion of surfactant –> atelectasis
CXR = fine reticular granularity of lung parenchyma
Can happen right after birth
Tx
- mech ventilation
- surfactant admin
Transient tachypnea
Usually follows uneventful normal term vaginal delivery or C section
LUngs clear
CXR = prominent pulm vascular markings, fluid lines in fissures, overaeration, flat diaphragm, sometimes pleural fluid
Persistent pulmonary hypertension of the newborn
Should be suspected in all term and post term infants w/ cyanosis with or without fetal distress
Unresponsive hypoxia to 100% O2
Meconium aspiration syndrome
Usually in term or post-term infants
Patchy infiltrates
Coarse streaking of both lung fields
Increased AP diameter
Flattening of diaphragm
When should babies stop having meconium?
Day 3 of life
Pierre Robin Sequence
2/2 to hypoplasia of mandibular area
Tongue is posteriorly located preventing closure of posterior palatal shelves
Micognathia
Glossoptosis
Cleft soft palate
Can be a feature of other syndromes:
- edwards
- Stickler (AD, early arthritis, ocular problems)
Potter sequence
Bilateral renal agenesis –> incompatible with life
Hx of oligohydramnioas
Death by pulmonary hypoplasia
Potter facies:
- hypertelorism
- epicanthal folds
- low set ears
- micrognathia
- limb abnormalities
Fetal Alcohol syndrome
EtOH #1 teratogen to which fetus exposed
Features: 3 main facial dysmorphisms: - small palpebral fissures - smooth philtrum - thin vermillion border
- growth deficiency / FTT
- MR
- irritable, hyperactive
- fine motor dysfunction
- microcephaly
- maxillary hypoplasia
- short nose
Cardiac:
- septal defects
Beckwith-Wiedemann Syndrome
Hemihypertrophy
Macroglossia
Omphalocele
Hypoglycemia
Apnea cyanosis
Feeding issues
Seizures
Wilms tumor common
Route US and a-fetoprotein should be performed 6 mo - 6 yo
Survivors of infancy do ok
Sotos syndrome
Rare genetic DO
Excessive growth during first 2-3 years of life
+/-
Autism
MR
Hypotonia
Tx symptomatic
Prognosis is normal life span
Formerly most common cause of hydrous fetalis
Rh incompatibility
Now parvovirus can do this
How can you figure out if baby in utero has anemia?
Blood flow through MCA can correlate with Hg status and know if in utero baby has anemia
Bloody vaginal discharge in neonate…what do you do?
Reassure
Infants < 3 mo can sometimes get vaginal spotting or bleeding as estrogen from mom is clearing from infant circulation
small gestational age infants higher risk for…
Hypoxia Polycythemia Hypoglycemia Hypothermia Hypocalcemia
Reason for increased risk of intraventricular hemorrhage in premie
Capillary fragility of subependymal germinal matrix adn immature autoregulation of cerebral blood flow
Screen for this with serial head US!!
- 25-50% cases asymptomatic
Ways to reduce incidence of intraventricular hemorrhage
Prevent preterm labor
Antenatal admin of maternal steroids
Physiologic jaundice
Starts day 2 of life –> age 1-2 weeks
Increased unconj bilirubin because:
- At birth, RBC is increased w/ shorter lifespan –> high Hg turnover and bili production
- bili clearance is slow at first because hepatic uridine diphosphogluconurate glucuronosyltransferase (UGT) doesn’t reach adult levels until 2 yo
- –> asian newborns have decreased UGT activity compared to other ethnicities
- enterhepatic recycling increased in newborns b/c sterile newborn gut can’t break down bilirubin to urobilinogen for fecal excretion –> more bili resorbed and recycled until gut is colonized
Birth weight should be regained by age
10-14 days
Healthy infants normally lose up to 7% of BW in first 5 days of life - no tx required.
Prune belly syndrome
Malformation mostly in males
Lax wrinkled ab wall
dilated urinary tract
intraabdominal testicular tissue
Oligohydramnios
Congenital hip dislocation, club feet
NO genetic predisposition
