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
