Premature / LBW / NICU Flashcards
What type of small babies can you get [3]
SGA
LBW
IUGR
What causes LBW [5]
Idiopathic Placental insufficiency Chromosomal, Malformation Infection - TORCH / CMV / syphillis Monochorionic monoamniotic twins
What causes placental insufficiency [5]
Maternal factors: IHD, DM High BP, PET Placental Abruption Sickle cell Smoking / alcohol
What are common problems in LBW [8]
- Perinatal hypoxia - increased haematocrit, bilirubin and plasma viscosity
= Polycytheaemia as hypoxia = produce more - Hypoglycaemia
- Hypothermia
- Thrombocytopenia - BM concentrating on making RBC
- NEC
- Meconium aspiration syndrome as stressed
- IRDS as less surfactant
- Infection
What are long term problems of LBW [5]
DM, Obesity Hypertension, IHD, Stroke Reduced Growth Renal failure Lung - asthma
What is mild LBW and what is considered extreme
LBW <2.5kg
Extreme <1kg
What is symmetric LBW [2]
OFC and weight in the same percentile
Pathogenesis of symmetric IUGR
What causes symmetric [4]
1st trimester insult
Affects all DNA
Chromosomal
Infection / TORCH
Teratogens
Severe smoke / alcohol
Will symmetric LBW improve
Unlikely as will never have enough cells
What is asymmetric [2]
OFC spared
Weight <10 centile
What causes asymmetric LBW [3]
3rd trimester insult
Placental insufficiency
PET
Small amount of smoking/drug use
Why is LBW associated with hypothermia
Lack of fat stores
Why is LBW associated with hypoglycaemia
No glycogen reserve as IUGR throughout pregnancy so constantly used up
Hematological sequelae of hypoxic state in utero of LBW babies cause [5]
- Increased haematocrit 20-22 (normal 18-20)
- Increased bilirubin as have to break down
- Increased plasma viscosity (VTE / slow circulation)
- Polycythaemic to increase RBC as hypoxic
- Thrombocytopenia as BM making RBC
How do you treat the hypoxic state of LBW babies
Partial exchange transfusion
Why does premature make you more prone to infection [3]
IgG transfer in 3rd trimester
Immune system is underdeveloped
Interventions in premature
Chorioamnionitis
Do you worry more about pre-term but appropriate for gestational age or the pre-term SGA?
Pre-term appropriate gestational age higher risk of complications
SGA baby will have been under stress in the womb so produce natural steroids to mature lungs
What is most important in LBW babies
Nutrition
What causes pre-term babies [4]
Idiopathic
External: Smoking, Malnutrition
Maternal infection (chorioamnionitis), PET, DM
Factors that stretch womb: Polyhydramnios, Twins
APH, PPROM
What is term
37-42
Mild prematurity
32-37
Moderate
28-32
Extreme
<28 weeks
What is important if premature [5]
Fluid - dextrose TPN if long term, Syringe feed, NG Vitamins Abidec Iron at 28 days Establish feet
Complications of respiratory distress syndrome if untreated? [3]
Respiratory distress
Exhaustion
Respiratory failure - hypoxia/. hypercapnia
What are RF for IRDS [3]
Pre-term
DM
C-section
How do you Dx [2]
Blood gas
CXR - indistinct heart border
How do you prevent [2]
Antenatal steroid, 12 hours apart
Delay birth with tocolytics
How do you Rx [2]
O2 - nasal or mask or just flow to maintain pressure
CPAP - open and inflate alveoli after intubation
Complications [4]
Retinopathy
Renal failure due to hypoxia
PTX
Bronchopulmonary dysplasia
When do you use CPAP
If only problem is keeping airway open
What is Ddx of IRDS [5]
Sepsis TTN Meconium aspiration Congenital lung Cardiac anomaly
What causes bronchopulmonary dysplasia [4]
Pathophysiology [2]
- volume barotrauma
- atelectasis
- oxygen toxicity
- infection via ETT
inflammation and scarring of lungs (necrotising bronchiolitis with alveolar fibrosis)
What does bronchopulmonary dysplasia cause [4]
Persistent hypoxia
Difficulty weaning off ventilation
Severe bronchiolitis
Poor feeding
How do you treat bronchopulmonary dysplasia [4]
Steroids
Surfactant
High calories feeding
diuretics (SPIRNOLACTONE and FUROSEMIDE)
What are complications of bronchopulmonary dysplasia [5]
GORD Feeding issue Decreased IQ Cerebral palsy Asthma
What minor issues is there in terms of respiration [3]
Apnoea >15s
Desaturation
Irregular breathing
How do you treat minor respiratory problems in premature infants [2]
Caffeine - neuroprotective and stimulates resp
NCPAP
When does IVH occur
Ax
Px [2]
First 72 hours
Ax: rupture of germinal matrix blood vessels
Px:
- blood vessels in germinal matrix, lateral to ventricles lack structural support and rupture
- particularly with abnormal cerebral autoregulation
Signs of IVH [8]
Seizure Bulging fontanelle Cerebral irritability, drowsiness Diminished or absent moro reflex Poor muscle tone Apnoea Pallor, cyanosis Failure to suck, shrill cry
How do you Dx [3]
Cranial USS as fontanelle hasn’t closed
MRI
Bloods
How do you Rx [3]
Fluid replacement
Anticonvulsants
Acetazolamide to prevent post-hemorrhagic hydrocephalus
What do you do if hydrocephalus / raised ICP [2]
Drainage
Shunt
What are complications of IVH [3]
Post haemorrhagic hydrocephalus if clot occlude
Decreased IQ
Cerebral palsy
What types of intracranial haemorrhage are there
IVH = most common in pre-term
SAH
Subdural after forceps
What causes hypoxic ischaemic encephalopathy? [7]
What is HIE?
IVH Placental insufficiency, abruption Cord prolapse Long delivery Maternal hypoxia Infection Anaemia
HIE is brain injury secondary to hypoxic ischemic insult and reperfusion injury
What does mild HIE present with [2]
Hyperalert
Hypertonia
HIE associated symptoms [3]
Ix [2]
Resp depression
Coma
Encephalopathy within first 24h ie seizures
Ix: capillary gas (at birth pH <7 and base excess -12), flat line in EEG
Describe EEG in HIE
EEG
Flat single line
How do you Mx HIE[4]
Support seizure
Avoid hyperthermia
Therapeutic hypothermia
Cranial USS, MRI and neurodevelopmental f/u
What are the complications HIE [5]
Cerebral palsy Epilepsy Blind Deaf Learning difficulty
Describe general resuscitative management in HIE [4]
Describe therapeutic hypothermia [2]
General principles:
- Intermittent positive pressure ventilation (IPPV)
- Avoid hyperthermia
- Cerebral function analysis monitoring
- Phenobarbital
Therapeutic hypothermia:
- baby cooled to 33o for 72h and then rewarmed slowly over 12h with sedation
Ax of neonatal sepsis. Differentiate between early and late onset by the typical causative organisms [3]
Risk factors of early onset sepsis [5]
Risk factors of late onset sepsis [5]
Early onset: transplacental or ascending infection by GBS, E.coli, listeria
Late onset: environmental infection by coagulase negative staphylococci, staph aureus, GBS, candida
Risk factors:
- Early onset: prolonged rupture of membranes, maternal infection, preterm labour, fetal distress, mucosal/skin breaks in neonate
- Late onset: central lines and catheters, congenital malformations e.g. spina bifida, severe illness, malnutrition, immunodeficiency
How does sepsis present? [7]
Fever/hypothermia Resp distress Poor feeding, lethargy Jaundice Hypoglycaemia, Seizure Shock, Collapse DIC
What are the complications of group B strep [5]
Meningitis DIC Pneumonia, Respiratory failure Hypotension Shock
How long does GBS last
Early = 1 week
Can recur up to 3 months
How do you investigate sepsis? [7]
Admit NICU SEPSIS 6 protocol FBC, CRP (repeat as could be delayed) Blood cultures VBG, Glucose CXR LP
What do you do if 1 RF
Observe
What do you do if 2RF or red flag
Full sepsis screen
IV Ax to baby
Even if no signs
What antibiotics to give EMPIRICALLY:
Early onset [2]
Late onset [2]
Early onset:
- IV pencilling or vancomycin
- gentamicin
Late onset:
- IV flucloxicillin
- +gentamicin
When can you stop gent
2x CRP <4
What do you do when cultures back? [4]
Vanc if MRSA
Metronidazole If surgical or abdominal concerns
Cefotaxime for meningitis
Amoxicillin for listeria
Etiology of neonatal hypoglycemia - describe 3 mechanisms
- Limited glucose supply: prematurity, perinatal stress
- Hyperinsulinism: diabetic mothers, labetalol use in pregnancy
- Increased glucose utilisation: SGA, LGA, hypothermia, sepsis
What should all irritable babies get [3]
U+E
BG
Sepsis screen
How do you treat [3]
IV 10% glucose
Regular electrolyte if on fluid
Hydrocrotisone
What causes haemorrhage disease of newborn
Vit K defiicency
How does HDON present [3]
Bruising
Jaundice
IVH / kidney
