Neonatal jaundice Flashcards Preview

Obstetrics and Gynaecology > Neonatal jaundice > Flashcards

Flashcards in Neonatal jaundice Deck (29):
1

Etiology

1.UnConjugated
a. Physiologic
b. Pathologic
-->i. Hemolytic
Membrane
Enzyme
Hemaglobin
Immune: ABO, Ph
Non-immune: Splenomegaly, sepsis, AV malformation
-->ii. Non-hemolytic
Hematoma
Polycythemia
Sepsis
HypoT
Gilberts

2. Conjugated (always pathologic)
a. Hepatic
Infectious: sepsis, TORCH, hep B
Metabolic: galactosemia, A1AT, CF, hypoT
Drugs
TPN
Idiopathic neonatal hepatitis
b. Post hepatic
Biliary stresia
Choledochal cyst

2

When is jaundice visible

1. When levels 85-120umol/L

3

When is jaundice more severe/prolonged

1. Prematurity
2. Acidosis
3. Hypoalbuminemia
4. Dehydration

4

How common is jaundice

1. 60% of term infants develop jaundice

5

Onset and progression of physiologic jaundice, pathophysiology

1. Onset at day 2-3 of life, resolution by day 7
2. PathoP
+RBC number and shortened lifestyle
Immature glocorynyl transferase->poor conjugation
+Enterohepatic circulation
Decreased uptake and binding by liver cells

6

Breastfeeding jaundice

1. Due to lack of milk supply->dehydration->more exagerated physiologic jaundice

7

Breastmilk jaundice, cause, progress

1. 1 per 200 infants
2. Glocorinyl transferase inhibitor in the milk
3. Onset day 7 of life->peaks at 2-3 weeks and resolves by 6 weeks.

8

When should pathologic jaundice be considered

1. When

9

Risk factors

1. Maternal
Ethnic Asian
Complications during pregnancy->Rh, ABO, diabetes
Breastfeeding
2. Perinatal
Birth trauma->cephalohematom
Prematurity
3. Neonatal
DIfficulty establishing breast feeding->deH
Infection
Genetic, metabolic
Polycythemia
Drugs

10

Initial assessment of all babies with jaundice

1. Assess for risk factors for jaundice and significant hyperbilirubinemia
?family history of hemolysis
6. Examination
Feeding
Weight
Hydration
Risks: preterm, 2 weeks
7. Identify the cause if not clear from history/examination
Total serum bilirubin
FBC + film
Blood group maternal and baby
DAT
NBST if applicable
8. Refer to pediatrician/neonatologist if results abnormal
9. Fluid management

11

If

Medical emergency
1. Measure and record serum bilirubin within 2 hours
2. Manage as per treatment graphs
3. Neonatalogy/pediatrician review within 6 hours
4. Commence phototherapy whilst awaiting results
5. Do investigations
6. Manage fluids

12

24 hours to 10 days

1. Measure and record TcB or serum bilirubin w/i 6 hours
2. Manage as per treatment line
3. Commence phototherapy if >6 hours for results, baby has risk factors, TCB >250mmol/L or above treatment threshold, jaundice below the nipple
4. Medical review required
5. DO investigations if cause not obvious
6. Manage fluids
7. Be sure to treat underlying sepsis
8. Arrange F/U with midwife/GP to ensure adequate oral intake
2 weeks for term, >3 weeks for preterm

13

Prolonged jaundice management

1. Usually breastfeeding related
2. Investgate
Total and conjugated bilirubin
FBC + film
Reticulocyte count
Blood group
DAT
TFTs
Review NBST
3. Seek expert advice if +conjugated, dark urine and pale stools
4. Fluid management
5. Consider additional investigations

14

Signs of acute bilirubin encephalopathy

1. Bilirubin toxicity in first few weeks of life
2. Lethargic
2. Irritable, temperature instability, opisthotonos, spasticity
3. Apnea
4. Hypotonia, poor sucking reflex->hypertonic, high pitched cry, seizures and coma

15

Definition and manifestations of chronic bilirubin encephalopathy

Clinical findings of chronic bilirubin encephalopathy include
o Athetoid cerebral palsy with or without seizures
o Developmental delay
o Hearing deficit
o Oculomotor disturbances including paralysis of upward gaze
(Parinaud’s sign)
o Dental dysplasia
o Intellectual impairment

16

Define kernicterus

1. Yellow staining of basal ganglia
2. Frequently used to refer to the clinical sequelae

17

When is kasai procedure best done

1. Before 45-60 days of life

18

Prevention of jaundice

1. Early and frequent breastfeeding
2. Blood group, Rh, Coombs test on cord blood if mothers blood group is negative or unknown
3. Risk assessment before d/c and plan f/u
4. Monitor all infants for jaundice 12 horly

19

What is Kramer's rule

1. The level of jaundice on infant->face->trunk->arms and legs can crudely correspond to serum bilirubin level

20

Infants at higher, medium and lower risk

1. Higher
35-37 + risk factors
2. Medium
38 + risk factors
3. Low
38 + well

21

Brief overview Mx

1. Fluids
2. Phototherapy
3. Exchange transfusion
4. IV immunoglobulin if hemolytic and not responding

22

How does phototherapy work

1. Exposure to light photoisomerises unconjugated bilirubin->+solubility->can then be excreted in feces and urine
2. Blue light is best 460-490nm

23

How to increase effectiveness of phototherapy

1. +amount of skin exposed
2. +intensity of the light
3. Additional overhead light
4. Closer light to baby

24

Biliblanket

1. Outpatient
2. Allows therapy in open cot with mum on ward

25

Monitoring phototherapy and cessation

1. Adequacy hydration and nutrition, continue breastfeeding
2. Temperature
3. Clinical improvement
4. Potential signs of bilirubin encephalopathy
5. Cease when SBR

26

Potential complications of phototherapy

1. Overheat
2. Water loss, diarrhea->hydration
3. Rash
4. Parental anxiety/separation->educate and reassure
5. Ileus->bowel motions, distention
6. ?Retinal damage
7. Bronzing artefact from conjugated

27

Indications for exchange transfusion

1. Rh disease, no transfusion in utero
2. Cord blood Hb 80 umol/L
4. Visible jaundice 340 and + and due to hemolysis
6. Preterm or sick may need at lower BR

28

Risks of exchange transfusion

1. Apnea
2. BradyC
3. Cyanosis
4. Vasospasm
5. Air embolism
6. Infection
7. Thrombosis
8. Necrotising enterocolitis
9. Rarely death

29

Monitoring following exchange transfusion

1. Monitor Hb
2. May need top up transfusion
3. Assess for complication