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1

mom received meperidine (Demerol) and phenargan during labor due to inadequate spinal anesthesia and baby is blue, floppy and poorly responsive, what to do?

-initiate positive-pressure ventilation (PPV) by bag and mask
-naloxone (Narcan IV, IM, SQ or endotracheal) administration may transiently reverse the effect of the narcotic (meperidine), which is likely the cause of the neonatal respiratory depression (narcosis)

2

The 1-minute Apgar score helps to determine an infant's well-being in the period just prior to delivery, and scores ? historically have been used to indicate the need for immediate resuscitation

less than 3
-the 5-minute score is one indicator of how successful the resuscitation efforts were

3

A child presents with immediate respiratory distress, scaphoid abdomen, cyanosis, and heart sounds displaced to the right side of the chest, think what condition?
how to manage?

diaphragmatic hernia
-will often have pulmonary hypoplasia, endotracheal intubation is the best course of action
-Bag-and-mask ventilation will cause accumulation of bowel gas (which is located in the chest) and further respiratory compromise.

4

Choanal atresia results in respiratory distress when a child stops crying; immediate treatment is ?

intubation until surgical correction can be completed

5

if neonatal HR is still less than 60 beats/min despite positive-pressure ventilation (PPV) with 100% oxygen, what next step?
if HR still less than 60 what next?

give chest compressions for 30 seconds
If the HR is still less than 60 beats/min, then drug therapy (usually epinephrine) is indicated.

6

causes of tachypnea in the IDM (infant of diabetic mother)

*hypoglycemia, RDS, HCM, hypocalcemia, polycythemia, and clavicle fracture

7

fetal hyperinsulinism begins in the second trimester resulting in ?

fetal macrosomia and increased fetal oxygen requirements

8

Maternal hyperglycemia very early in gestation can cause ?

NTDs and congenital heart disease

9

Fetal insulin production causes increased glycogen production deposited in fetal liver, heart, kidneys, muscles..leads to complications such as

difficult delivery, HCM, polycythemia due to incr. O2 requirements, RDS due to insulin interfering with cortisol's ability to induce surfactant production

10

hypoglycemia is a blood sugar less than ?
symptoms?

less than 40 mg/dL
lethargy, listlessness, poor feeding, temperature instability, apnea, cyanosis, jitteriness, tremors, seizure activity, respiratory distress, hypothermia (vomiting is NOT a symptom)

11

macrosomia defined

Larger than normal baby with the birth weight exceeding the 90th percentile for gestational age, or any birth weight more than 4 kg.

12

If hyperglycemia is present in the first trimester, an increased risk for congenital anomalies of ?

the CNS, heart, kidneys, and skeletal system (such as caudal regression syndrome in which there is hypoplasia of the sacrum and lower extremities)

13

a neonate with a blood glucose level of less than 40 mg/dL with any symptom of hypoglycemia requires ?
If no symptoms of hypoglycemia are present what to do?

IV glucose

the infant is refed and the glucose is remeasured 30 minutes after the feeding.

14

what is a metabolic abnormality commonly seen in IDM and presents as irritability, sweating, or seizures

hypocalcemia, treat with IV calcium

15

how does polycythemia (HCT more than 65) develop in a macrosomic neonate and how does it present

Macrosomia in utero increases O2 requirement, and the relative placental insufficiency leads to increased production of EPO
-may give a ruddy or plethoric hue to the infant's skin

16

Polycythemia contributes to elevated ? levels
can cause?
how to treat?

bilirubin
hyperviscosity syndrome with resultant venous thrombosis in the renal veins, cerebral venous sinus, or mesenteric veins
treated with increased hydration and in rare instances partial exchange transfusion

17

Neonatal hyperbilirubinemia appears when ? results from higher rates of ? and a limited ?

first week of life
bilirubin production (RBCs are lysed at too rapid a rate)

limited ability to excrete it (ie, transmission of unconjugated bilirubin to the liver is interrupted; liver enzyme deficiencies preclude appropriate metabolism of the unconjugated material)

18

risk factors for neonatal jaundice

male gender, cephalohematoma, Asian ancestry, breast-feeding, maternal DM, prematurity, polycythemia, trisomy 21, delayed bowel movement, upper GI obstruction, hypothyroidism, swallowed maternal blood, and a sibling with physiologic jaundice.

19

Unconjugated or Indirect Hyperbilirubinemia ddx

Hemolytic disease (ABO, Rh, or
other minor blood group incompatibility), Structural/metabolic abnormalities of RBCs (hereditary spherocytosis, G6PD deficiency), Hereditary defects in bilirubin conjugation (Crigler-Najjar—Types I and II, Gilbert disease)
Bacterial sepsis, Breast milk jaundice, Physiologic jaundice

20

Conjugated or Direct Hyperbilirubinemia ddx

Conjugated biliary atresia, Extrahepatic biliary obstruction, Neonatal hepatitis (Bac, Viral, Nonspecific, TPN related), Short bowel related, Inspissated bile syndrome, Postasphyxia, α1-Antitrypsin deficiency, Neonatal hemosiderosis

21

does conjugated or unconjugated bilirubin cause neurotoxicity?

unconjugated (conjugated cannot cross BBB)

22

Clinical and laboratory findings of hemolysis

rapid rise of serum bilirubin level (more than 0.5 mg/dL/h), anemia, pallor, reticulocytosis, and hepatosplenomegaly.

23

kernicterus is a neurologic syndrome resulting from unconjugated bilirubin deposition in brain cells, especially the ? Less mature or sick infants have greater susceptibility. common initial signs ?

basal ganglia, globus pallidus, putamen, and caudate nuclei

Lethargy, poor feeding, and loss of Moro reflex

24

ETCO

END-TIDAL CO CONCENTRATION corrected for ambient CO; provides a noninvasive assessment of bilirubin production.

25

TRANSCUTANEOUS BILIRUBINOMETER (TcB):

device that is placed on infant's skin and produces light at several wavelengths that then measures its reflection after interacting with the serum bilirubin in the microcirculation beneath the skin. used as alternative to blood test to noninvasively measure serum bilirubin

26

Jaundice usually begins on the ? and then progresses to the ? Full-term newborns with physiologic jaundice usually have peak bilirubin concentrations of ? between the second and fourth days of life

face and then progresses to the chest, abdomen, and feet.
5 to 6 mg/dL

27

Findings suggestive of nonphysiologic jaundice

(1) appearance in the first 24 to 36 hours of life
(2) bilirubin rate of rise greater than 5 mg/dL/24 h
(3) bilirubin greater than 12 mg/dL in a full-term infant without other physiologic jaundice risk factors listed
(4) jaundice that persists after 10 to 14 days of life

28

Causes of nonphysiologic jaundice

septicemia, biliary atresia, hepatitis, galactosemia, hypothyroidism, cystic fibrosis, congenital hemolytic anemia (eg, spherocytosis, maternal Rh, or blood type sensitization), or drug-induced hemolytic anemia

29

jaundice presenting within the first 24 hours of life requires immediate attention; causes include ?

erythroblastosis fetalis, hemorrhage, sepsis, cytomegalic inclusion disease, rubella, and congenital toxoplasmosis

30

Significant hyperbilirubinemia requires a diagnostic evaluation

indirect and direct bilirubin concentrations, Hgb level, reticulocyte count, blood type, Coombs test, and peripheral blood smear examination.

31

commonly used treatment for unconjugated hyperbilirubinemia

phototherapy: light converts the skin's bilirubin isomerization into a more easily excreted form

32

Exchange transfusion is needed in a small number of jaundiced infants who do not respond to conservative measures, what does it involve?

Small aliquots of the infant's blood are removed via a blood vessel catheter and replaced with similar aliquots of donor blood

33

risks of exchange transfusion

air embolus, volume imbalance, arrhythmias, acidosis, respiratory distress, electrolyte imbalance, anemia or polycythemia, blood pressure fluctuation, infection, and necrotizing enterocolitis.

34

maternal ingestion of ? during pregnancy decreases the risk of neurologic damage in a jaundiced newborn

phenobarbital, as it induces glucuronyl transferase (UGT), thus reducing neonatal jaundice

35

Crigler-Najjar syndrome

Severe deficiency of uridine diphosphate glucuronosyltransferase
type I have a severe deficiency, causing high bilirubin levels and encephalopathy. Treatment is phototherapy. Encephalopathy is rare with Crigler-Najjar syndrome type II, in which bilirubin levels rarely exceed 20 mg/dL.

36

early-onset neonatal sepsis

1st 6 days of life, 85% in 1st day, , orgs from mom's GU tract: GBS, E coli, H influenzae, and L monocytogenes, presents with pneumonia and sepsis

37

late-onset neonatal sepsis

after 7 days, before 90 days, orgs from environment

38

Examination findings seen frequently with pneumonia (more commonly seen in early-onset disease)

tachypnea, grunting, nasal flaring, retractions (costal or substernal), decreased breath sounds, and cyanosis

39

findings common in sepsis and meningitis

Temperature instability, tachypnea, hypotension, and bradycardia, poor feeding, hypoglycemia

40

Overwhelming shock is manifested as

pallor and poor capillary refill.

41

think early-onset GBS (rather than noninfectious etiology of lung problems) if

PROM, apnea, hypotension in the first 24 hours of life, a 1-minute Apgar score less than 5, and rapid progression of pulmonary disease

42

Factors associated with increased risk for early-onset GBS disease

ROM more than 18 hours before delivery, chorioamnionitis or intrapartum temperature greater than 100.4°F (38°C), previous infant with GBS infection, mother younger than 20 years, and LBW or prematurity (less than 37 weeks of gestation)

43

manifestations of late-onset GBS

bacteremia without a focus, meningitis, pneumonia, septic arthritis, osteomyelitis, or cellulitis

44

treatment of neonatal sepsis?
if GBS is isolated as the sole pathogen, narrow to ?

IV gentamycin/tobramycin and ampicillin for 48-72 hrs
stop if cultures are negative and pt is well
if s/s of sepsis and negative cx, continue abx
if + cx, may continue for 10-21 days
others: 1st/2nd gen cephs, vanc

IV penicillin G

45

hermaphroditism

Discrepancy between gonad morphology and external genitalia

46

Think CAH in an infant with ambiguous genitalia and these symptoms

failure to thrive (failure to regain birth weight, progressive weight loss), vomiting, and dehydration

47

interventions for CAH infant

fluid resuscitation, electrolyte repletion, adrenocorticoid replacement (hydrocortisone helps to inhibit excessive production of androgens and further virilization)

48

an important first step in the laboratory evaluation of infants with ambiguous genitalia

Karyotype analysis using activated lymphocytes

49

If CAH is suspected, biochemical markers might include an elevated ?

serum 17-hydroxyprogesterone level

50

how to determine whether a block in testosterone synthesis or 5a-reductase deficiency exists

measure urinary steroids and plasma androgens before and after administration of ACTH and hCG

51

other studies for ambiguous genitalia

ultrasonogram or pelvic MRI, urogenital sinus x-ray after contrast injection, and fiberoptic endoscopy
typically NOT laparascopy

52

what condition has functional testicular tissue, with normal or high testosterone levels, have 46,XY karyotypes, yet appear as phenotypically normal females with short or atretic vaginas

testicular feminization