OB Module 5: Complications of the Newborn Flashcards
(219 cards)
1
Q
How has fertility rate in the US recently
A
it hit a 3% drop from 2016 to 17 leading to a historic low
2
Q
Birth rates have lowered in all age groups except…
A
women in their 40s
3
Q
In 2017 pre term ___ ___rose 9.93%
A
birth weight
4
Q
How many deaths per 100,000 live births occur in the US
A
597
5
Q
Leading Causes of Infant Death
A
- Congenital Malformations, Deformations, and Chromosomal Abnormalities
- Disorders related to short gestation and low birthweight: not elsewhere classified
- SIDS
6
Q
Infant Morality means…
A
infant death before their first birthday
7
Q
Infant morality gives information…
A
on maternal and infant health and is also an important marker for overall health of society
8
Q
What is the importance of the NICU
A
they were made in the US in the 1960s and newborn mortality rate
9
Q
Maternal Risk Factors
A
Low Socioeconomic Status (effects the below point)
Limited access to health care, especially prenatal care
Environmental exposure; high altitude (affects oxygenation)
grand multiparity (exhaustion from so many babies)
multiple gestation pregnancy
poor maternal nutrition
pre existing maternal conditions
maternal age and parity
complications of pregnancy
10
Q
___ and ___ mothers are at the highest risk for complications
A
youngest and oldest
11
Q
What are some pre existing maternal conditions that are risk factors for complications
A
heart disease
DM
HGTN
preeclampsia
renal disease
12
Q
What are some neonatal risk factors for complications
A
birth weight
gestational age
type and length of newborn illness
environmental exposures in uteri
delayed bonding
13
Q
SGA
A
small for gestational age
less than 2500 grams or 10th percentile on birth chart - so about 5.5 pounds or less
14
Q
LGA
A
large for gestational age
greater than 4000 g and 90th percentile -8.8 pounds or more
15
Q
Less than ___ weeks is preterm
A
37
16
Q
Early Term is when
A
between 37-38 weeks and 6 days
17
Q
Full term is when
A
39 weeks to 40 weeks and 6 days
18
Q
Late term is when
A
41 weeks to 41 weeks and 6 days
19
Q
Post term is when
A
anything beyond 42 weeks
20
Q
What is essential to picking up complications early in the newborn period
A
regular assessments and vital sign checks
21
Q
What is essential to do since newborns have little reserve
A
it is essential to address complications as they start in order to minimize potential long term impacts
22
Q
What are the categories of Risk factors for Newborn Complications?
A
- Prenatal or Antenatal (during pregnancy) -maternal or fetal
- Intrapartal (during delivery)
- Postpartum (after delivery)
23
Q
SGA is under ___ g or ___ pounds. that is the ___ percentile
A
25000 g or 5.5 lbs. 10th percentile
24
Q
SGA is based on ___ not ___
A
weight not time (it can be pre term or post)
25
What is associated with SGA
decreased placental function
26
IUGR
Intrauterine Growth Restriction
SGA + Additional Complication
May be thin, pale, loose dry skin, umbilical cord thin and dull instead of thick and shiny
May appear small all over or malnourished
27
IUGR is related to what things?
Gestational Diabetes / Uncontrolled Diabetes
rubella
CMV
toxoplasmosis
syphilis
malnutrition
lung disease
HTN or heart disease
kidney disease
anemia
sickle cell anemia
smoking
drinking alcohol or drug abuse
chromosomal defects in the fetus
multiple gestations - twins or triplets
28
What things can cause SGA
asphyxia
aspiration syndrome
hypothermia
hypoglycemia
polycythemia
*things associated with decreased placental perfusion/function*
29
IUGR is SGA + Additional complications: What are some of the additional complications
congenital malformations
intrauterine infections
continued growth difficulties
cognitive difficulties
30
Example Nursing Diagnoses for IUGR/SGA
Risk for impaired gas exchange related to meconium aspiration
risk for ineffective thermoregulation secondary to decreased subcutaneous fast
altered nutrition
risk for altered parenting related to lack of knowledge of infant care and prolonged separation of infant and parent secondary to illness
31
Not all SGA is ___
IUGR
32
What are some risk factors for LGA
Infant of a diabetic mother
Erythroblastosis fetalis
cardiac etiology - transposition of great vessels
multiparity
prior history of macrocytic infant
postdate gestation
maternal obesity
male fetus
genetics
33
Complications of LGA infants
cephalopelvic disproportion
increased incidence of Cesarean birth and induction of labor
hypoglycemia, polycythemia, hyper-viscosity
jaundice secondary to hyperbilirubinemia
34
Cepalopelvic Disproprtion
when the babies head does not fit through the pelvis (LGA)
35
Characteristics of an infant of a diabetic mother
Macrosomia (over 4000g or 8.8 pounds) or SGA
ruddy in color
excessive adipose tissue
large umbilical cord and placenta
decreased total body water
excessive fetal growth from exposure to high levels of maternal glucose
potential Organomegaly (increased organ weight)
36
25-42% of diabetic pregnancies are macrosomia for the infant d/t...
insulin
37
Why can a diabetic mother give birth to an LGA or SGA infant
depends on blood flow and vascular impact of the diabetes on the mom before and after the pregnancy
SGA suffered from intrauterine malnutrition and have almost no glucose reserves for L&D - so uteroplacental circulation was impaired leading to poor growth patterns and hypoxemia --> Fetal distress in labor
38
Why are infants of diabetic mothers prone to shoulder dystocia
they have excessive fat on the shoulders and trunk oftentimes
this leaves them also predisposed to brachial plexus injury and overall body weight
39
LGA infants are often ___ in the first few hours post birth
hypoglycemic
40
Cephalopelvic Disproportion or Dysfunctional Labor pattern means...
a C Section may be needed
41
Complications in the Infant d/t the mother having diabetes
Hypoglycemia
Hyperbilirubinemia and Jaundice
Birth Trauma
Polycythemia
Respiratory Distress Syndrome
congenital Birth Defects like cardiac anomalies (most common), GI anomalies, and sacral agenesis
Poor eating habits
42
Why is birth weight NOT a reliable measure of maturity?
for example, LGA infants may not eat well and act like a preterm child despite looking past maturity
43
Erythroblastosis Fetalis
hemolytic disease of the newborn
results from a blood disorder like ABO incompatibility or Rh incompatibility
44
Most common incompatibility between mom and baby
ABO
Mom is O carrying Anti A and Anti B antibodies and the baby is A B or AB
45
Combs Test
a positive test will show agglutination and the baby will be jaundiced from high bilirubinemia (may need photolight therapy)
may cause slight anemia but should not need treatment - occurs with ABO incompatibility
also tests Rh incompatability
46
Rh Incompatibility
mom is Rh - and baby is Rh +
not usually a problem until subsequent pregnancies
1:1000 pregnancies
rarely seen now due to Rhogam in third trimester and after childbirth if baby is Rh+
47
___ and ___ increase with each pregnancy for a baby with Rh+ blood
risk and severity
48
What happens in a second pregnancy if this child is also an Rh + infant?
mild anemia to severe hemolytic anemia, edema, enlarged liver spleen and possible hydrops
49
Tests and treatments for erythroblastosis fetalis
Blood type
Coombs test
Rhogam
Phototherapy
50
Hydrops Fetalis
a severe abnormal accumulation of fluid in 2 or more fetal compartments including ascites, pleural effusion, pericardial effusion, and skin edema
rare but very fatal / high mortality
51
In some patients, hydrops fetalis is also associated with ...
polyhydramnios and placental edema
52
Causes for Hydrops Fetalis
Hemolytic incompatibilities, severe anemias
Parovirus B19
Congenital Anomalies
Fetal Hemorrhage - intracranial intraventricular, hepatic laceration, subcapsular, placental subchorial
tumors
fetomaternal hemorrhage
twin to twin transfusion
isoimmune fetal thrombocytopenia
53
It used to be thought ___ ___ causes hydrops fetalis, but what disproved this?
Rh incompatibility - but Rhogam came in and it still occurs
54
How can twin to twin transfusion cause hydrops fetalis
if one identical twin receives too much blood and the other doesn't get enough the hydrops can occur
early detection needs to see this to deliver the baby early
55
Isoimmune Fetal Thrombocytopenia causing Hydrops Fetalis
mom body recognizing non self antigens on fetal platelets and making antibodies to attack
the non self antigen comes from the dads side
if it is mild no treatment is needed, but severe cases cause fetal intracranial hemorrhaging leading to hydrops
56
Preterm infant
defined as an infant that is delivered less than 37 weeks gestation
could lead to needed NICU care
57
Preterm infant ability to survive is dependent on...
degree of prematurity and infants own strengths and weaknesses
58
In general infants born at less than ___ weeks are non viable
24 weeks
*however some 23 week yo infants have survived but need serious help*
59
If at delivery the infants eyes are fused and it weighs less than 500 grams...
general resuscitation is not done
60
Why do we bring pre term babies to the NICU
to see if the can maintain temperature, have respiratory efforts, can eat and tolerate food, maintain blood sugar etc
If all those things are ok then they can go to the normal nursery
61
Micro preemies need level ___ NICU
4
62
What are some complications associated with preterm infants in regard to alteration in respiratory and cardiac physiology?
apnea of prematurity
PDA - patent ductus arteriosus
RDS - respiratory distress syndrome
BPR - bronchopulmonary dysplasia
IVH - intraventricular hemorrhage
anemia of prematurity
aspiration
63
Apnea of Prematurity
no breathing for at least a full 20 seconds
if not a full 20 seconds than it is bradypnea
leads to bradycardia because of immature resp centers
turn blue color and may physical stimulation or O2 supports to get them to breath
typically this is outgrown
64
Anemia of Prematurity
exaggerated response from hypoxic state in utero to the hyperoxi state in utero
it is a normocytic, normochomic, hyperregenerative anemia
low serum erythropoietin levels occur despite low Hgb levels
cannot make new RBCs to mature
BASICALLY EVERYTHING IS IMMATURE (maybe from not enough building blocks)
Reticulocyte counts watched carefully but it tends to resolve in 3-6 months
65
A major complication of being a preterm infant in regard to alteration in thermoregulation is ___
hypothermia
66
What are some important preterm GI alterations
hypoglycemia
necrotizing enterocolitis
67
What are some important preterm immunologic alterations
neonatal infection
68
What are some important preterm neurologic alterations
reactivity periods and behavioral states
69
What are some important preterm ocular alterations
retinopathy of prematurity
70
Necrotizing Enterocolitis
when food is not moving through the intestines like it should and bacteria cause gas formation
this increases abdominal girth as a gas bubble gathers and increases risk for perforation leading to sepsis and can be fatal
71
What are some s/s of Necrotizing Enterocolitis
bradycardia
apnea
color changes
infant looks sick
72
Treatments for Necrotizing Enterocolitis
stop feedings
gastric tube suctions to keep GI tract empty
high doses of antibiotics
possible ventilatory support and intubation support
strict feedings to make sure food is digested
73
Necrotizing Enterocolitis may occur when what is done too quickly
feedings
so we should educate that when a preterm infant cries or does sucking motions it may not mean they are hungry but rather just have an innate need to suckle
74
What does quietness after anger and annoyance indicate in an infant
being overwhelmed
75
Retinopathy of Prematurity
normal vessels in the eye should grow following the curve of the retina
However, premies have vessels growing into the vitreous humor in fingerlike projections that become tortuous and twisted and engorged and if they rupture it can lead to blindness
76
Treatment for Retinopathy of Prematurity
careful eye exams and surgery if there are abnormalities in order to prevent blindness
77
Ductus Arteriosus
blood vessel allowing blood to go around the fetal lungs prior to birth
after birth the lungs fill with air and this closes within a couple of days after delivery
78
Patent Ductus Arteriosus
when the ductus arteriosus does not close
it leads to abnormal blood flow between the aorta and pulmonary artery
more common in girls
occurs in premies commonly
79
S/s of Patent Ductus Arteriosus
fast breathing
poor feeding
tiring easily
auscultated murmurs
tachycardia
SOB
poor growth
80
Intraventricular Hemorrhage
high incidence in infants under 30 weeks gestation
occurs since premie cerebral vessels are very fragile and bleed into the brain
this is important to consider when moving or transporting premies as their heads cannot take jarring movements
81
RDS
Respiratory Distress Syndrome
Caused by lung prematurity
chest xray shows the atelectasis as hazy lung fields
82
What sort of infants get RDS?
60-80% are <28 weeks will develop
But even a full term baby can have it occur if there is no surfactant in the lungs
83
Common Predictors for RDS
Prematurity
C Section without labor
IDM (diabetes in mom)
2nd Twin`
84
Antepartal complications d/t RDS
hemorrhaging
asphyxia
85
How to treat RDS
give chemical surfactant
86
Consequences of RDS
lung scarring
increased risk of asthma (d/t scarring)
BPD - bronchopulmonary dysplasia
87
BPD
bronchopulmonary dysplasia
can occur if infant was on ventilation or oxygen for a long time
it is a chronic lung condition
greater risk for lung infections, respiratory sysital virus, and permanent bronchial changes occur
88
S/S of Respiratory distress syndrome (RDS)
cyanosis
grunting
inspiratory stridor
poor feeding
tachypnea
lethargy
intercostal, subcostal, and/or suprasternal spaces retractions
89
Hypothermia is a big problem in ____ and ___ infants since they lack ...
preme and SGA infants since they lack brown fat
90
Cold stress will cause...
hypoglycemia
hypoxia
metabolic acidosis
anaerobic metabolism
91
Increased respiratory distress d/t hypothermia is caused by ___ and ___
hypoxia and acidosis
92
Since there is so much energy used keeping themselves warm, there is no energy to ___ in the cold stressed child
eat
93
Causes of Hypothermia
Prematurity
IUGR
Other stressors like sepsis, birth asphyxia, hypoglycemia, respiratory distress
94
S/S of Hypothermia
respiratory challenges
bradycardia
seizure
feeding intolerance
lethargy
irritability
hypoglycemia
95
Ways to prevent and treat hypothermia?
warmers, isolettes, hats and blankets, skin to skin contact with blankets on
96
Most of the heat in an infant is lost from the ___
head
97
Term infants maintain temperature well after __ hours, but premature infants will need a ___ or ___ to maintain temperature
24; isolette or warmer
98
When is blood sugar lowest (when are they hypoglycemic) for infants?
1-2 hours after cord clamping
| may need an IV to compensate
99
Failure to increase blood sugar after ___ hours is pathologic for hypoglycemia
4 hours
100
What is the difference between ability to compensate for blood sugar between term and preterm infants?
term infants can usually compensate
preterm infants do not have the brown fat stores to compensate and cannot tolerate early feedings sufficient to maintain blood sugar levels alone
101
Any baby less than ___ mg/dL needs intervention like IV fluid feeding
40 mg/dL
102
Causes of Hypoglycemia
prematurity
IUGR
delayed feedings
increased need for glucose
need an increased uptake of glucose
inborn errors
diabetic mothers
103
What is interesting about the s/s presentation of hypoglycemia
you may not see any so you will need to check a chemstrip if indicated by history and protocol
104
S/S of Hypoglycemia
tremors/jittery --> seizures
abnormal cry (high pitched or weak)
respiratory distress --> apnea, irregular respiration, tachypnea, cyanosis
stupor, hypotonia, refusal to eat (d/t decreased brain sugars)
105
A cat like cry is indicative of...
cocaine addiction
106
How to prevent and treat hypoglycemia
early feedings
frequent monitoring
prevention of causative factors through temperature stability, treating respiratory difficulties, early IV (emergency use)
107
Why are infants so at risk for neonatal infection
because the immune system is immature, unable to produce adequate levels of antibodies, unable to localize infections, and incomplete mucosal defenses (like trapping) which allows the infant to be more readily colonized
108
The term newborn does have some temporary passive immunity from...
the mother
109
When can maternal infection be passed to the infant
transplacentally in utero
at time of delivery via contact contamination
after delivery through breast milk
110
Bacterial infections are classified as ___ onset or ___ onset
early or late
111
early onset neonatal infection
usually present from 24 hours to 1 week post birth (could be home by then)
tend to progress rapidly
10-25% risk of mortality
112
What are some associated bacteria with early onset neonatal infections
Group B Streptococcus
H Influenza
Listeria Monocytogenes
E Coli
113
Group B strep accounts for ___ % of neonatal infections
80%
114
We test the mom for Group B strep at ___ weeks but if delivered early without testing we must do a ___ to check the baby
36 weeks
CBC
115
What sort of things may be ordered with a neonatal infection
CBC
chemstrips
bilirubin levels
blood cultures
116
Late onset neonatal infection
usually presents after 2 weeks but can occur after the first week - they are definitely home by then
it progresses slowly
lower mortality rate but a higher morbidity rate
117
Associated organisms with late neonatal infection
S Aureus
S Epidermidis
Pseudomonas
Group B Streptococcus
118
___ ___ ___ can be early or late onset
Group B Streptococcus
119
Postmaturity
applies to any newborn born after 42 weeks gestation
120
Complications with Postmaturity
Potential intra-partal problems:
Cephalopelvic disproportion (CPD)
Shoulder Dystocia
Meconium Passage in utero is common
Placental function deteriorates
Respiratory complications
Vernix gone - skin is wrinkly, dry, peeling
121
Why is post maturity so rough on the placenta
it is supposed to deteriorate at term but after 40 weeks calcification begins and function deteriorates
this causes less O2 to the baby which leads to meconium passage
less O2 --> meconium in utero --> meconium is sterile but it is sticky and can be aspirated causing further respiratory issues
122
Issus occurring d/t postmaturity
Fetus is exposed to poor placental function --> hypoglycemia and asphyxia
impairment of nutrition and oxygenation
123
Postmaturity Syndrome
constellation of issues r/t to postmaturity including:
Hypoglycemia
Meconium Aspiration and Asphyxia
Polycythemia
Congenital Anomalies
Seizure Activity
Cold Stress
124
Meconium Aspiration Syndrome (MAS)
Complete or partial airway obstruction from inhalation of the meconium that can affect term and near term infants
frightening
can cause atelectasis, hyperinflation, or pneumonitis
125
What is required with meconium aspiration syndrome
intubation directly after birth to suction meconium from the airway
this is before breath is taken or crying begins so stimulation needs to be minimized until it is over
126
Meconium
first stool
dark green black and sticky
made of dead blood cells
127
How can we tell if meconium was passed in utero
if the amniotic fluid is green colored
128
Common Predictors of MAS
term or post term infants
rarely seen in <36 week gestation (preterm) unless they are severely O2 deprived and stimulated to pass
129
Complications arising from MAS
pneumothorax
pneumonia
persistent pulmonary HTN
bronchopulmonary dysplasia
neurologic complications
possible death
130
What will MAS look like on a CXR
ill defined predominantly perihilar opacities
131
Why can so many complications occur d/t MAS
because they are working hard to breath and the lungs are hyperinflated
132
Transient Tachypnea of the Newborn (TTNB)
Amniotic fluid that got into the lungs ("Wet Lungs")
occurs in term and near term infants
lasts 1-5 days
minimal hypoxia - self limiting
no meconium in the fluid
may need some O2 support
133
Respiratory rates are generally what in TTNB?
>100 breaths per minute
134
Common predictors of TTNB
C sections without labor (no squeeze to rid of fluid)
Precipitous delivery
prolonged labor
Male
Second Twin
135
What are the consequences of TTNB?
NO LONG TERM CONSEQUENCES - it is self limiting
They will be unable to nipple feed with a high RR and will need introduction to food slowly via IV or gavage (NG)
136
Infant cannot nipple feed with an RR ___
>70 (d/t aspiration risk)
137
What is the morbidity and mortality like with TTNB
there is none
138
What are the phases of TTNB
Phase 1 - grunting phase with grunting to open up the alveoli
Phase 2- tachypneic phase with RR 100-120
139
What is the path of fetal circulation
Right ventricle --> pulmonary artery --> ductus arteriosus --> aortic arch --> Body
140
Only __ to __% of R&L ventricular output goes to the pulmonary vessels. The rest bypasses...
5-10%; the lungs
141
What occurs to pressure and circulation at birth
there is a rapid FALL in pulmonary vascular resistance and pulmonary artery pressure accompanied by a 10 fold increase in pulmonary blood flow
142
Persistent Pulmonary Hypertension (PPN)
persistent fetal circulation after birth
occurs in near term, term, and post term infants
10-20% of the time it is idiopathic but can also occur from hypoxia or other delivery problems like abruption, meconium staining, etc
2 in 1000 children
143
Consequences of PPN
pneumothorax
hypotension and CHF
impaired kidney function
DIC
seizures
144
What are the interventions like for PPN
quite minimally invasive interventions but ones that are done to prevent lung damage
they need consistent oxygenation to prevent vasoconstriction - but if that occurs they need nitrous oxide on a level 4 NICU
145
Pneumothorax
Happens with alveolar over distention and rupture
can be spontaneous or d/t assisted ventilation
frequently there is another underlying pulmonary disease at work
may or may not require intervention
146
What is intervention in a pneumothorax like
they may or may not need it
if its less than 20% they will be able to recoup on their own but if more they need a chest tube - lung may reinflate on its own or require intervention
chest tube is attached to a continuous negative pressure system
147
What are the consequences of pneumothorax dependent on
underlying pathology
148
s/s of Respiratory Disorders (Global Symptoms)
tachypnea between 60-120 bpm with TTN
grunting
retracting
nasal flaring
hypoxia (cyanosis) - circumoral may occur first
transilluminator of a pneumothorax
149
How can we see a pneumothorax?
via transillumination in a dark room
if placed in the armpit it will show light on the affected side with the pneumothorax (it lights up)
150
Treatments for Respiratory Disorders
O2 support
continuous oximetry
chest PT (break up secretions)
keep temp, CS< fluids and electrolytes stable
monitor ABGs, CBC, BC
prophylactic antibiotics if questionable CBC or mom group B strep + (may be better than waiting 48 hours)
surfactant if RDS
chest tube if pneumothorax
151
What are some ways of giving oxygen support
Hood - Mixed air
Heated Flow Cannula - air humidified and warmed
CPAP
Oscillator
Ventilator and ET Tube
ECMO
152
CPAP
continuous positive airway pressure
baby is not intubated but a little pressure helps open the airways and get them breathing
153
Oscillator
special machine that does 200 revolutions over the chest per minute
very sophisticated
can mean survival for some children
154
ECMO
extracorporeal membrane oxygenation
quite specialized
it is like a baby version of a heart lung bypass where we oxygenate the blood for them
155
TORCH
represents a group of congenital infections that cause birthd efects
156
What does TORCH stand for
Toxoplasmosis
Other (infections)
Rubella
CMV
Herpes Simplex
157
What is included under other infections in torch
Hep B
Syphillis
Herpes Zoster (chicken pox)
HIV
158
TORCH is most serious when...
mom develops primary infection during pregnancy
may appear mild to her but has serious impacts on the baby
159
When can an infant contract congenital infections / TORCH
1. infection crosses the placenta
| 2. infant contracts while passing through the birth canal
160
Severity of infection in the mom ...
does not determine severity in the baby
161
What groups of women tend to have TORCH infections
ANY woman - they are equal opportunity
unrelated to cleanliness or socioeconomic status
162
Toxoplasmosis comes from
raw meat or cat litter
163
If mom has active lesions of herpes at labor..
we deliver via C section to prevent infection
164
PKU Test
newborn screening done on all babies (heel stick) to check for metabolic disorders
165
What are some common things tested for with Metabolic Disorders?
Phenylketonuria
Galactosemia
Hypothyroidism
Sickle cell Anemia
Congenital Adrenal Hyperplasia (CAH)
HIV
166
How many tests can be run on the small newborn screening blood samples
over 40 tests
167
Phenylketonuria (PKU)
lack of an enzyme - phenylalanine hydroxylase - leads to irreversible brain damage in 24 hours if they eat food with phenylalanine in it
168
Galactosomia
lack of enzyme that converts galactose to glucose
babies can get jaundice, weight loss, cataracts
169
Buetler Test
checks for galactosemia
170
A mom may refuse HIV testing, but...
we always test the baby in NYS - but we let mom know ahead of time
171
Hyperbilirubinemia
Jaundice
Yellowing of the skin due to the accumulation of bilirubin - it also accumulates in the brain
it occurs when breakdown of RBC happens faster than the liver and GI tract can remove them
172
Bilirubin
a byproduct of heme from the breakdown of Hgb
it is one of the components of bile and is yellow in color
173
Why are infants more prone to juandice
they have a higher rate of production d/t shorter lifespan of RBC and higher RBC concentration than adults
they also have lower liver function leading to slower bilirubin metabolism and more reabsorption in the intestine due to delay of passage
174
In most newborns, jaundice is...
physiological and considered harmless
175
What % of term and near term infants will become visible jaundiced? What about preterm?
60-70% Term and Near Term
80% Preterm
176
What is the leading cause of hospital readmission in the first 2 weeks of life
hyperbilirbinemia
177
Hyperbilirubinemia is the major cause for what in an otherwise healthy newborn
prolonged hospitalizations
178
Physiologic Causes of Hyperbilirubinemia
increased load of RBC breakdown from cephalohematoma, suction or forceps delivery, other bruising
liver immaturity
infant of diabetic mother
hepatic or bowel abnormalities
breastfeeding
179
Hemolytic causes of Hyperbilirubinemia
blood group incompatibilities
Rh negative mom
ABO incompatibilities
G6PD Deficiency
180
Breastmilk Jaundice - Type related to Poor Intake
most likely in first week of life
may not get adequate milk while establishing breastfeeding leading to elevated bilirubin due to increased reabsorption in the intestines
this also delays passage of meconium which has a lot of bilirubin in it that will be reabsorbed
181
Breastmilk Jaundice - type related to unknown etiology
occurs in the 2nd or later weeks of life and continues for several weeks
exact mechanism unknown but substance in moms milk may inhibit liver processing of bilirubin
182
What are some treatment options for breast milk jaundice
phototherapy
temporary supplementation with donor milk or infant formula or rarely interrupted breastfeeding
183
G6PD
glucose 6 phosphate dehydrogenase deficiency
causes milk to severe jaundice -- generally in males
passed via X chromosome
usually G6P helps process carbs and protects RBC from influence of harmful meds or infections
may not had any s/s
common in Sephardic Jewish and Mediterranean descent
184
Complications from Extreme Hyperbilirubinemia
Neurological complications including:
seizure
poor suck reflex
irritability
abnormal muscle tone
185
The major long term complication of extreme hyperbilirubinemia is ___
Kernicterus
186
Kernicterus
When bilirubin levels are high (over 20) it can enter the brain and causes this syndrome of complications
irreversible
187
What are some of the s/s of Kernicterus
seizure
hearing loss
motor deficits
vision loss
learning difficulties
death
188
Premature infants need to be treated when in regard to their hyperbilirubinemia levels in reference to term infants
treated at lower levels than term infants
189
Treatment for hyperbilirubinemia is evaluated in reference to...
how old the infant is in terms of hours and the babies size
190
What are some complicating factors for hyperbilirubinemia treatment
hypoglycemia
sepsis
*both affect decision to treat
191
How to test for Hyperbilirubinemia
Observation
transcutaneous Bilirubinometry
blood draws from a heel stick
192
What observations can be made for hyperbilirubinemia
cephalocaudal progression (head down) of jaundice
easy but the most unreliable test
193
Best way to test hyperbilirubinemia is via a ...
blood draw via heel stick
it gives a direct bilirubin level in mg/dL and gives the neonatal or total bilirubin level in the infant
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Treatment options for hyperbilirubinemia
phototherapy
hydration - feeding via breast or bottle or IV
exchange transfusion
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Why can we not do phototherapy on an infant with high direct bilirubin levels
it can permanently bronze the skin
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Why do we need to make sure hyperbilirubinemia infants are well hydrated
so the concentration of bilirubin is less and they can pass it and rid of it more
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Why is exchange blood transfusion sometimes done in hyperbilirubinemia?
a partial or full exchange of blood from a donor after the PKU test may be done to replace a large amount (75) of blood to prevent kernicterus
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Complications Associated with Maternal Substance Abuse
Fetal Alcohol Syndrome (FAS)
Maternal Drug Use/Abuse
Maternal Tobacco Dependence
Exposure to HIV/AIDS (d/t risky behavior)
Congenital Heart Defects
Caffeine, Tobacco, Alcohol impacts
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Neonatal Abstinence Syndrome (NAS)
Withdrawal
Infants withdrawing from many substances - not just illicit drugs
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what substances may cause NAS
cigarettes
caffeine
prescription pain killers
alcohol
street drugs
antidepressants
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Characteristics of Infant NAS/Withdrawal
high pitched cry
colic - early on and prolonged
poor sleep patterns
increased muscle tone and tremors
seizure
diarrhea
temperature instability
poor feeding
sneezing
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When may NAS begin
sometimes after 24 to 48 hours when the infant may be home already
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Why is stigmatization of drugs harmful to mothers
many women with substance use disorders may have late or no prenatal care as a result which leads to poor outcomes
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What is recommended women do regarding their addiction while pregnant?
NOT abruptly stop or wean off opioids even if they want to
this is because maternal withdrawal can increase the risk of miscarriage or intrauterine death
However these risks are higher if the mom gets no treatment so we must do drug treatment
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What are the safest plans for drug treatment for pregnancies with substance use disorders
Methadone or Buprenorphine treatment
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What is the objective for a mother with a SUD (substance use disorder)
maintain healthy gestation and prevent use of street drugs
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What is the issue with maintenance drug treatment for maternal SUD
they are increased to prevent withdrawal but it continues to expose the infant leading to risk for preterm delivery, low birth weight, fetal distress, placental abruption, miscarriage, intrauterine death, severe HTN, or maternal/neonatal death
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Studies show what correlation between dose of opioid and level of NAS severity
no correlation between the two
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Nursing Considerations for NAS
Test infants when drug usage is suspected (urine and meconium drug screening)
Limit withdrawal symptoms (via morphine)
Involve social services
Monitor and support parental involvement
Treat other complications as necessary
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How do meconium and ursine testing capture differences in drug usage?
urine is more for short term usage (recent)
meconium can capture long term usage (throughout pregnancy)
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Why can meconium show long term / history of drug usage
because it begins to form in the 12-15th week of gestation
this can reveal up to the last 4-5 months of use
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Why do negative drug results not rule out drug exposure in the infant
because we do not have tests for every drug out there
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One infant ___ affects and causes another
complication
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It is important to do what in regard to infant complications
predict and act promptly
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___ infants need more proactive treatment than term infants
preterm
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The baby is a ___ in the NICU and we need to do what?
patient; so we must keep their best interest a priority but at the same time we also need to be supportive of the parent
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Always do what as much as possible in OB
promote parental involvement
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Parents need what
need to explain what is happening and what to expect
need frequent reinforcement due to the NICU environment
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Kangaroo Care
skin to skin contact
has positive outcomes when intubated
