Perinatal and neonatal medicine

Question 1

Rubella in pregnancy

Answer 1

Notify health protection unit  (HPU)
HPU may want to test B19
NO effective Mx
Recommend rest, fluids and paracetamol
Stay off work, avoid contact w/other pregnant women after developing rash
Refer to obst. for risk

Question 2

CMV in the neonate Drug Mx

Answer 2

IV ganciclovir/ PO valganciclovir

Question 3

Toxoplasmosis in neonate Mx

Answer 3

1st line: pyrimethamine + sulfadiazine + Ca folinate

adjunct: pred

Question 4

Newborn Hearing Screening

Answer 4

EOAR: Earphone over ear plays sound which causes echo if cochlear function is normal (if normal not achieved move onto:)
AABR: computer analyses EEG waveforms evoked by series of clicks

Question 5

Neonatal nerve palsies

Answer 5

Most will resolve completely

Question 6

Resp. distress syndrome

Answer 6

Oxygen and ventilation
CPAP or AV via tracheal tube possible
other: high flow hum. 02, mechanical v.,
Exogenous surfactant via ET tube

Question 7

Neonatal pneumothorax

Answer 7

Immediate decompression + O2 + chest drain if tension

Question 8

Neonatal PDA

Answer 8

Closed using: IV indomethacin, prostacyclin synthase inhibitor, ibuprofen
If fail: surgical ligation or percutaneous catheter device closure

Question 9

Necrotising Enterocolitis

Answer 9

Ix: AXR, cultures
Stop oral feed
broad spec Abx (ceotaxine/vancomycin)
If perf/necrosis: surgery
Parenteral nutrition always required, often ventilatory/circulatory support
long term Cx: strictures, malabs. if resection

Question 10

Neonatal jaundice Ix

Answer 10

Haematocrit
Blood group of mother and baby
DAT (+did mother receive aniti-D?)
FBC and film (spherocytes)
Blood G6PD levels
Culture blood, urine, CSF if ?infection
TSH
LFTs
Bili

Question 11

Assessment of Neonatal jaundice

Answer 11

Visually assess baby in light
Measure bilirubin:
- Serum: If jaundice within 24hrs of birth or GA <35w
- Transcutaneous: GA >35w or jaundice >24hrs of life (if >250umol check serum bili)
Check bili 6hrly until below threshold or becomes stable/falling

Question 12

Risk of developing Kernicterus

Answer 12

increased risk if
serum bili >340umol in >37w GA
Rising >8.5umol/hr
Fx of bilirubin encephalopathy: poor feed, lethargy, hypotonia

Question 13

Mx of neonatal jaundice

Answer 13

Threshold table:
- No Mx
- Phototherapy (+/- IVIG)
- Exchange transfusion
If baby clinically well, GA >38 and >24hrs old w/bili within 50 of phototherapy threshold:
- repeat 18hrs for any RiskFactors , 24hrs for no RF baies

Question 14

Phototherapy in Neonatal jaundice

Answer 14

450nm (green-blue)
Photobilirubin and lumirubin
Dont need conj. -> excreted
Can stop once >50umol below Rx threshold

Question 15

Monitoring in neonatal phototherapy

Answer 15

Serum bili 4-6hrly
Monitor temp
protect eyes
encourage short bf breaks (<30m)
Check for rebound hyperbili at 12-18hrs

Question 16

Indications for intensive phototherapy

Answer 16

1. bili >8.5umol inc. /hr
2. within 50umol of threshold for exchange trx >72hrs from birth
3. Bili doesnt respond witihin 6hrs
   - reduce intensity once bili >50 from exchange trx threshold

Question 17

Other option for neonatal jaundice

Answer 17

IVIG - adjunct in cases of RhHDN, ABO HDN, or if serdum bili >8.5umol/hr

Exchange Trx:
Above threshold OR if Sx of bili encephalopathy
Double-volume exchange used in babies
during trx do NOT stop phototherapy
Measure serum bili within 2hrs

Question 18

PACES counselling of Neonatal jaundice

Answer 18

Explain is common:
if: <1d, >14d will Ix cause
Physiological often
Mx: light therapy
- not harmful but eyes protected and regular bloods
- bf can continue
- need to stay in for another blood at 12-18h
Resources:
NHS choices Neonatal jaundice
Bf network
Bliss (prem/sick babies)

Question 19

Meconium Ileus

Answer 19

gastrograffin enema (n-acetylcysteine and option too)
Sx if ineffective

Question 20

Meconium aspiration

Answer 20

Ix: CXR (?pneumomediastinum), FBC+CRP, culture
If normal term infant w/mec stained amniotic fluid but NO Hx of GBS observe
If any risk factors or lab findings suggestive of infection consider Abx: ampicillin + gent
In sev cases: O2 and CPAP

Question 21

Persistent pHTN of neonate

Answer 21

CXR: normal heart but pulmonary oligaemia
Urgent echo to rule out CHD
Mx:
Mec. vent+circ support
Inhaled NO (vasodilator)
Sildenafil
?Oscillatory vent.
Sev. but reversible; extracorporeal membrane oxygenation

Question 22

Congenital diaphragmatic hernia

Answer 22

Once Dx large NG tube passed and suction applied to present distension of intrathoracic bowel
req. surg

Question 23

Early onset sepsis (<72hr) Ix

Answer 23

FBC U+E CRP
Cultures
Urine dip and MSU
LP (ALL infants <1m, 1-3 appear unwell or WCC <5 or >15, (or if FNS/blood culture +ve req. examination and culture))
CXR

Question 24

Early onset sepsis Abx

Answer 24

Immediate no wait for results
IV should cover:
GBS, listeria, other G+, G-
e.g. Benzylpenicillin/amoxicillin + gentamicin
If CRP -ve and infant well Abx can be stopped after 48hrs

Question 25

Late onset sepsis >72hrs pathogens

Answer 25

Most common: coagulase -ve staph (epidermis) others: G+: S aureus, E faecalis G-: klebsiella, pseudomonas

Question 26

Late onset sepsis (>72hrs) Abx

Answer 26

``` Ampicillin + gent/cefotaxime Vanc + gent ?sensitivities Vanc for coag. -ve Staph. if all else fails mero NB long term broad spec ABx risks invasive fungal infection ```

Question 27

Neonatal meningitis

Answer 27

Uncommon but high mort and morb 1/3 maj. sequele late Sx: bulging fontanelle, opisthotonos Mx: ampicillin + 3rd gen ceph. (cefotaxime) Cx: cerebral abcesss

Question 28

Paediatric sepsis 6

Answer 28

1. O2 2. IV access (cultures, glucose, A/C/V gases) 3. IV broad spec Abx 4. IV fluids 5. Senior clinicians involved early 6. Vasoactive intropic support considered early (if normal parameters not achieved after 40ml/kf resus

Question 29

GBS neontate

Answer 29

Benzylpenicillin or ampicillin AND Gent./cefotaxime/ceftriaxone supportive

Question 30

Listeria monocytogenes neonate

Answer 30

amox. co-trimoxazole NB. trimethoprim CI in preg if systemic: IV benpen+Gent

Question 31

Conjunctivitis in the neonate

Answer 31

Clear w/water/saline in most cases Neomycin for staph/strep Sx Gonococcal infection: sample, stain, culture the discharge (Mx: 3rd gen ceph.) Chlamydia: PO erythromycin 2w Best practice: opthalmic azithromycin/erythromycin antihistamines/artificial tears for viral conjunctivitis

Question 32

Herpes simplex in neonate

Answer 32

If mother has primary dx or genital lesions within 6weeks of del. then c-sec If earlier PO aciclovir from 36w Aciclovir can be given to baby during risk period

Question 33

HBV in neonate

Answer 33

infants of HBsAg+ mothers receive vaccination after birth (birth,1m,6m) and HBV IG Mothers: antiviral monotherapy tenofovir or lamivudine

Question 34

Neonatal hypoglycaemia

Answer 34

Prevented by early and freq feed Glucose IV if severe Glucagon and hydrocortisone too if you like Aim for glucose >2mmol/L

Question 35

Cleft lip/palate

Answer 35

Specialised feeding may be req. ?airway problems (e.g. Pierre RObin) Pre-surgical lip tapping, oral appliances, PNAM may narrow cleft Definitive Mx: surgery