Perinatal, neonatal + newborn Flashcards
When to evaluate the APGAR score?
At minute 1, then minute 5. Every 5 minutes thereafter as long as resuscitation is continuing.
APGAR score definition
Not predictive of long-term outcome, but an improvement system for det first minutes of life.
0-4: poor
5-7: fair
8-10: good
How low should the bradycardia be, before starting CPR?
Hart rate drops <60/minute after five effective inflation breaths and 30 seconds of effective ventilation
How to calculate APGAR score?
Appearance: 0 - blue, 1 - cyanotic/pale, 2 - pink
Pulse: 0 - absent, 1 - <100/min, 2 - >100/min
Grimace (reflex): 0 - absent, 1 - facial grimace, 2 - active withdrawal
Activity (tone): 0 - absent, 1 - weak/passive/flexion, 2 - active
Respiration: 0 - absent, 1 - irregular, shallow, 2 - crying
TTN (transient tachypnoea of the newborn)
- Most common cause of respiratory distress in term infants
- Caused by delay in the resorption of lung liquid
- More common in C-section
- Symptoms: grunting
- Dx: X-ray may show fluid
- Tx: PPV
Ventilation breath ration
3:1
Asymmetrical growth restriction
- When the weight or abdominal circumference lies on a lower gentile that that of the head.
- Cause by placenta fails to provide adequate nutrition late in pregnancy, but head is relative spared at the expense of liver glycogen and skin fat
- Dx: Uteroplacental dysfunction secondary to;
1. Maternal pre-eclampsia
2. Multiple pregnancies
3. Maternal smoking
4. Ideopathic - Increased risk of obesity and DM2 later in life
Symmetrical growth restriction
- Head circumference is equally reduced with the rest of the body
- Caused by prolonged period of poor intrauterine growth starting in early pregnancy
- Dx
1. Small but normal fetus
2. Fetal chromsome disorder or syndrome
3. Congenital infection
4. Maternal drug and alcohol abuse
5. Maternal chronic medical condition or malnutrition - Infants more likely to remain small permanently
After birth, a growth-restricted infant are liable to:
- Hypothermia
- Hypoglycemia (poor fat an glycogen stores)
- Hypocalcemia
- Polycythemia
Vitamin given right after birth?
Vitamin K
- To prevent hemorrhagic disease of the newborn
How to test for DDH (developmental dysplasia of the hip)?
- Barlow manoeuvre = hip is held flexed and the femoral head is adducted and pushed downwards. If hip is dislocated, femoral head will be pushed posteriorly out of the acetabulum
- Ortolani manoeuvre = to see if the hip can be returned from its dislocated position back into the acetabulum.
Risk factors of DDH
- Girls (6-fold increase)
- Positive family history (20% of affected infants)
- Breech birth
- Neuromuscular disorder
A tense fontanelle may be due to:
- Baby is crying
- Hydrocephalus
- Late sign of meningitis
Abnormal pulse pressure in femoral pulses, can indicate:
- Reduced
- Coarctation of the aorta (confirmed by measuring BP in arms and legs)
- Increased
- Patent ductus arteriosus
Primitive reflexes
- Moro: sudden extension of head causes symmetrical extension, then flexion of arms
- Grasp
- Rooting: head turns to stimulus when touched near the mouth
- Stepping response
- Asymmetrical tonic neck reflex: infant adopts an outstretched arm to the side to which the head is turned
- Sucking reflex
Port wine stain
- Present from birth, usually grows with infant
- Due to vascular malformation of the capillaries in the dermis
- Unilateral, distribution of the trigeminal nerve
- Can be associated with Sturge-Weber syndrome
Immediate effects after hypoxic-ischemic encephalopathy
- Hypoxemia –> Hypercarbia –> Respiratory acidosis
- Low CO –> Decreased tissue perfusion –> Ischemia –> Metabolic acidosis –> Capillary leak, edema
HIE, multi-organ failure
- Encephalopathy: abnormal neuralgic signs, seizures
- Respiratory failure: persisten pulmonary HTN
- Myocaridal dysfunction: Hypotension
- Metabolic: Hypoglycemia, Hypocalcemia, Hyponatremia
- Renal failure
- DIC
Erb palsy
Upper nerve root (C5 and C6 injury
Usually resolves completely
Other causes of surfactant deficiency than preterm
- Infants of diabetic mothers
- Genetic mutations in the surfactant genes
The benefits of giving clucocorticoides antenatally in expected preterm deliveries
- Reduces RDS
- Reduces bronchopulmonary dysplasia
- Reduces intraventricular hemorrhage (IVH)
RDS definition
- Also called hyaline membrane disease
- Deficiency of surfactant –> lowers surface tension –> widespread alveolar collapse and inadequate gas exchange
RDS symptoms, Dx, and Tx
Symptoms: - Tachypnoea >60 breaths/minute - Laboured breathing with chest wall recession (particularly sternal and subcostal indrawing) - Nasal flaring - Expiratory grunting - try to create positive pressure - Cyanosis - if severe Dx: - Chest x-ray: Hypoexpanded, atelectasis, granular or "ground glass" appearance. Tx: - Surfactant directly into the lungs - NIV - CPAP - Intubation
Patent ductus arteriosus
- Normal: close within first week of life
- Shunting: left to right
- Most common in preterm with RDS
- Associated with maternal Rubella infection
- Symptoms: Asymptomatic or apnea, bradycardia, increased oxygen requirement
- Increased pulse pressure, “bounding”pulses
- Systolic murmur may be audible - “machinery”
- If symptomatic –> Indomethacin (PGE synthesis inhibitor) or Ibuprofen
Preterm fluid requirement
60-90 ml/kg 1s day of life, then increased by 20-30 ml/kg per day until reached 150-180 ml/kg (about day 5 of life)
Preterm nutritional supplements
- Phosphates
- Calcium
- Vitamin D
- Iron
- Prebiotics and probiotics for preventing necrotizing enterocolitis
Symptoms of necrotizing enterocolitis
- Feed intolerance
- Vomiting (may be bile stained)
- Distended abdomen
- Fresh blood in stool
X-ray features for necrotizing enterocolitis
- Distended loops of bowel
- Thickening of the bowel wall with intramural gas (pneumatosis intestinal = pathognomonic)
- May be gas in the portal venous tract
Tx of necrotizing enterocolitis
- Stop oral feeding
- Broad spectrum antibiotics
- Parenteral nutrition
- Sometimes mechanical ventilation and circulatory support
- Surgery if bowel perforation
IVH (intraventricular hemorrhages)
- Happens because highly vascularization lining the ventricles
- Typically occur in the germinal matrix above the caudate nucleus
- Most occur within the first 72h of life
- More common following perinatal asphyxia and in infants with severe RDS
- Antenatal glucocorticoids reduce incidence
Periventricular leukomalacia (PVL)
- Bilateral multiple cysts within the brain parenchyma –> definitive loss of white matter.
- Following brain ischemia or inflammation
- 80-90% risk of spastic diplegia, often with cognitive impairment
Cause and Tx of retinopathy in prematurity
- Vascular proliferation –> may progress to retinal detachment, fibrosis and blindness
Tx: - Laser therapy
- Intravitreal anti-VEFG (anti-vascular endothelial growth factor)
Definiton of Bronchopulmonary Dysplasia (BPD)
- Infants who still have an oxygen requirement at a postmenstrual age of 36 weeks
- Damage from
1. Delay in lung maturation
2. Pressure and volume trauma from artificial ventilation
3. Oxygen toxicity
4. Infection
Problems in preterm infants
- Respiratory: RDS, Pneumothorax, BPD, Apnea, Desaturation,
- Circulation: Hypotension, Patent Ductus Arteriosus
- Temperature control
- Nutrition: Nasogastric tube feeding, Feeding intolerance
- Infection: Main problem is nosocomial infection
- GI: Necrotizing enterocolitis
- Metabolic: Hypoglycemia, Electrolyte disturbances, Osteopenia of prematurity
- Eyes: Retinopathy
- CNS: IVH, Hydrocephalus, Periventricular leukomalacia
- Other: Jaundice, Anemia, Hearing
Physiology of newborn jaundice
- Marked physiological release of Hb from the breakdown of RBC because of high Hb concentration at birth
- RBC lifespan is short (70 days)
- Hepatic bilirubin metabolism is less efficient in the first few days of life
What is Kernicterus?
- Encephalopathy resulting from the deposition of unconjugated bilirubin in the basal ganglia and brainstem nuclei
- Occur when the level of unconjugated bilirubin exceeds the albumin-binding capacity of bilirubin
Manifestations of kernicterus
- Acute manifestations:
- Lethargy
- Poor feeding
- ‘High-pitched cry’
- Severe cases:
- Meningismus
- Irritability
- The baby lies with an arched back (opisthotonos)
- Hypotonia
- Seizures
- Coma
At which level does babies become clinically jaundiced?
Bilirubin >80 micromol/l
Rhesus haemolytic disease
Cause of jaundice: Indirect, Coombs (+)
- Anemia
- Hydrops
- Hepatosplenomegaly
- Rapidly developing severe jaundice
Triggers of jaundice in G6PD
- Oxidant (ASA, Sulfa drugs, Antimalarias, Fava beans)
- Infection and severe illness
Causes of jaundice appearing <24h of age
- Haemolytic disorders:
- Rhesus incompatibility
- ABO incompatibility
- G6PD deficiency
- Spherocytosis
- Pyruvate kinase deficiency
Causes of jaundice appearing >24h of age - 2 weeks of age
- Physiologic jaundice
- Breast milk fed
- Dehydration
- Infection
- Haemolysis
- Crigler-Najjar syndrome (Glucuronyl transferase deficiency)
- Gilbert syndrome
Causes of prolonged (>2 weeks / >3 weeks in preterm) unconjugated hyperbilirubinaemia
- “Brest milk jaundice” = most common cause
- Infection
- Congenital hypothyroidism
Value and signs of conjugated hyperbilirubinaemia
>25 micromol/l Signs: * Baby passing dark urine * Unpigmented pale stool * Hepatomegaly * Poor weight gain
Causes of conjugated (direct) hyperbilirubinaemia
Direct - always pathological!
- Neonatal hepatitis syndrome
- Sepsis
- TORCH
- Hypothyroidism
- Galactosemia
- Choledochal cyst
- Biliary atresia
Complications of meconium aspiration
- Mechanical obstruction
- Chemical pneumonitis
- Infection
- Air leak –> pneumothorax and pneumomediastinum
- May develop persistent pulmonary hypertension of the newborn
Conditions leading to persistent pulmonary hypertension
- Birth asphyxia
- Meconium aspiration
- Septicaemia
- RDS
Clinical features of neonatal sepsis
- Fever or tmp instability or hypothermia
- Poor feeding
- Vomiting
- Apnea and bradycardia
- Respiratory distress
- Abdominal distension
- Jaundice
- Neutropenia
- Hypo/hyperglycemia
- Shock
- Irritability
- Seizures
- Lethargy, drowsiness
Most common source of infection in NICU
Indwelling central venous catheter, invasive procedures that break the protective barrier of the skin, and tracheal tubes.
Most common pathogen causing nosocomially acquired infections
Staph. epidermidis (coagulase-negative
Most common organisms causing neonatal sepsis (up to 3 months of age)
- Group B Streptococcus (S. Agalactiae)
- E. coli
- Listeria monocytogenes
Complications of neonatal meningitis
- Cerebral abscess
- Ventriculitis
- Hydrocephalus
- Hearing loss
- Neurodevelopmental impairment
Conjuctivitis
Purulent discharge with conjunctival injection and swelling of the eyelids
- Within 48h of life: Gonococcal infection
- At 1-2 weeks of age: Chlamydia trachomatis (Tx. oral erythromycin for 2 weeks)
Risk factors for hypoglycemia in first 24h of life
- IUGR (poor glycogen stores)
- Preterm (poor glycogen stores)
- Born to mothers with DM (hyperplasia of islet cells –> high insulin levels)
- Large-for-dates
- Hypothermic
- Polycythaemic
- Ill for any reason
Symptoms of hypoglycemia
- Jitteriness
- Irritability
- Apnea
- Lethargy
- Drowsiness
- Seizures
Aiming level of blood glucose
2,6 mmol/L
Typical features of neonatal seizures
- Repetetive, rhythmic (clonic) movements of limbs that persist despite restraint
- Eye movements
- Changes in respiration
What causes need to ble excluded first in neonatal seizures?
- Hypoglycemia
- Meningitis
Causes of neonatal seizures
- HIE (hypoxic-ischemic encephalopathy)
- Cerebral infarction
- Septicemia/meningitis
- Metabolic:
- Hypoglycemia
- Hypo/hypernatremia
- Hypocalcemia
- Hypomagnesemia
- Intracranial haemorrhage
- Cerebral malformations
- Drug withdrawal, e.g. maternal opiates
- Congenital infections
- Kernicterus
Most common cause of perinatal stroke
Ischemia of middle cerebral artery
- Mechanism = thrombotic, either thromboembolism from placental vessels or sometimes secondary to inherited thombophilia
When to do surgical repair of cleft lip and cleft palate?
Cleft lip: at 3 months of age
Cleft palate: 6-12 months of age
What are the features in Pierre Robin sequence?
- Mirognathia
- Posterior displacement of the tongue (glossoptosis/retroglossia)
- Midline cleft or the soft palate
Clinical presentation of esophageal atresia
- Persistent salivation
- Drooling from the mouth
- Later:
- Cough and choke when fed –> cyanotic episodes
- May be aspiration of saliva from mouth and acid from stomach into lungs
VACTERL association
V - vertebral defects A - anal atresia C - cardiac defects (VSD) TE - tracheo-esophageal fistula R - renal defects L - limb defects (radial)
Small bowel obstruction symptoms
- Persisten vomiting (bile stained unless above ampulla of Vater)
- Delayed or absent meconium passage
- Abdominal distension (more prominent the more distal the obstruction)
- High lesion –> present soon after birth
- Lower lesions –> may not present for some days
Small bowel obstruction causes
- Atresia or stenosis of the duodenum (1/3 have Down’s)
- “Double bubble” on x-ray
- Atresia or stenosis of the jejunum or ileum
- Malrotation with volvulus
- Meconium ileus (almost all affected have CF)
- Meconium plug
Large bowel obstruction causes
- Hirschsprung disease
- Rectal atresia
Pathophysiology of Hirschsprung disease
- Absence of the myenteric nerve plexus in the rectum, which may extend along the colon
- More common in boys and Down’s
Exomphalos (omphalocele)
Abdominal contents protrude through the umbilical ring, covered with a transparent sac formed by the amniotic membrane and peritoneum
Gastrochisis
Bowel protrudes through a defect in the anterior abdominal wall adjacent to the umbilicus, no covering sac
The 4 major problems in preterm infants
- RDS –> BPD (bronchopulmonary dysplasia)
- ROP (retinopathy)
- IVH (intraventricular haemorrhage)
- NEC (necrotizing enterocolitis)
What are the risk of smoking during pregnancy?
- Low birth weight
- Increased risk of miscarriage and stillbirth
- Risk of sudden infant death syndrome
What are the benefits for pre-pregnancy folic acid supplements?
- Reduce the risk of neural tube defects
- Low-dose recommended for all women
- High-dose recommended for high risk women: previous family history, DM or using anticonvulsants
What are the benefits of glucocorticoid therapy perinatally?
- Given before preterm delivery (at lest 24h before delivery)
- Accelerates lung maturity and surfactant production - reduces incidence of RDS
- Reduces incidence of intraventricular hemorrhage
- Reduces incidence of neonatal mortality
What can the fetus develop if rhesus isoimmunization?
- Hydrops fetalis
- Edema
- Ascitis
What defects in the fetus can oligohydramnios cause?
- Pulmonary hypoplasia
- Limb and facial deformities from pressure in on the fetus (feks. Potter syndrome)
What is polyhydramnios associated with?
- Maternal diabetes
- Structural GI abnormalities (e.g. atresia in the fetus)
What are the risk factors for preterm delivery?
- Previous preterm infant
- Short inter-pregnancy interval (<6 months)
- Maternal age (<20 or >35)
- Obesity
- Ethnicity
- Multiple births
- Maternal infection
- Smoking and substance misuse
- Maternal psychological or social stress
What are the fetal associations with maternal diabetes?
- Congenital malformations (6% risk)
- Increased incidence of cardiac malformations, sacral agenesis, hypoplastic left colon - IUGR
- Macrosomia (25% have a birthweight >4kg)
- Neonatal hypoglycemia
- RDS
- Hypertrophic cardiomyopathy - of cardiac septum
- Polycythemia - infant look plethoric (florid, red-faced)
Clinical features of neonates with hyperthyroid
- Irritability
- Weight loss
- Tachycardia
- HF
- Diarrhea
- Exophthalmos
What are maternal use of SSRIs associated with?
Persisten pulmonary hypertension of the newborn
Clinical features of fetal alcohol syndrome
- Growth restriction
- Characteristic face
- Saddle-shaped nose
- Maxillary hypoplasia
- Absent philtrum
- Short, thin upper lip
- Developmental delay
- Cardiac defects
Drugs that should be avoided during pregnancy
- Anticonvulsants
- Cytotoxic agents
- Iodides/propylthiouracil
- Lithium
- SSRIs
- Tetracycline
- Thalidomide
- Vitamin A and retinoids
- Warfarinq
Clinical features of drug withdrawal in neonate
- Jitteriness
- Sneezing
- Yawning
- Poor feeding
- Vomiting
- Diarrhea
- Weight loss
- Seizures
TORCH infections
T - Toxoplasma gondii O - Other (Syphilis, Varicella zoster) R - Rubella C - CMV H - Herpes
Congenital Rubella
- Cataracts
- Deafness
- Congenital heart defects (PDA)
- Rash: Blueberry muffin spots
What is the most common congenital infection?
CMV
Clinical features in congenital CMV
- Microcephaly with periventricular calcifications
- Petechia with thrombocytopenia
- Other:
- Hepatosplenomegaly
- Hearing loss
- Cerebral palsy
- Epilepsy
- Cognitive impairment
Clinical features of toxoplasmosis
- Retinopathy, chorioretinitis
- General cerebral calcifications
- Hydrocephalus
When is the infant susceptible to maternal varicella infection?
Within 5 days before or 5 days after delivery.
Infant then need protection - zoster Ig, Aciclovir if any development of infection.
Clinical features of syphilis
- Characteristic rash of palms and soles of the feet
- Osteochondritis
- Periostitis
What are the fetal oxygen saturation?
- 65% of upper body
- 35% of lower body
What factors initiate breathing at birth?
- Thermal (cold)
- Tactile
- Hormonal (increase in catecholamine levels)
* Catecholamine levels also stimulate reabsorption of alveolar fluid
What is the mean time to establish regular breathing?
30 seconds
- On average, the first breath occurs 6 seconds after delivery
After delivery, when should chest compressions be given?
If heart rate dops below 60 beats/minute after 5 effective inflation breaths and 30 second of effective ventilation, compressions should be given
