Perinatal + Neonatal issues Flashcards Preview

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Flashcards in Perinatal + Neonatal issues Deck (88)
1

What do you use the Apgar score for?

Helps ID infants needing resuscitation

Also helpful to evaluate resuscitation efforts

2

How often give Apgar scores?

1 min

5 min

every 5 min after

3

Which Apgar scores need resuscitation?

0-3 at 1 min

4

Birth injuries

Avoidable and unavoidable injuries during L&D

Cephalhematoma
Caput succedaneum
SubQ fat necrosis
Brachial palsy
Facial palsy
Clavicular fx
Subconj hemorrhage

5

Cephalhematoma

SubPERIOSTEAL bleed

DOES NOT cross suture lines
- b/c limited to bone

Can feel rim around edge

Resolve spontaneously over several months

Common cause of jaundice

6

Caput succedaneum

Swelling of scalp 2/2 pressure exerted on that part during L&D

CROSSES suture lines

Resolves in a few days

7

Subcutaneous fat necrosis

Hx of difficult L&D

Rubbery, firm nodules on cheeks or buttocks and extremities

Usually resolve --> but can become calcium deposits in lesions

8

Clavicular fx - tx?

Tx not needed

Will feel crepitus over fx
Asymmetric moro

9

Coloboma

a hole in one of the structures of the eye, such as the iris, retina, choroid, or optic disc.

caused when a gap called the choroid fissure, which is present during early stages of prenatal development, fails to close up completely before a child is born

10

Aniridia

Absence of iris

assoc w/
- hemihypertrophy --> Wilms tumor

11

Hemihypertrophy + Aniridia --> what is going on?

Wilms tumor

12

Branchial cleft cyst

failure of obliteration of the second branchial cleft (or failure of fusion of the second and third branchial arches)

Usually unilateral

Can become infected

13

Congenital torticollis

Twisted neck
2/2 Injury to SCM during delivery

Tx muscular torticolis with stretching exercises

14

Breast hypertrophy

In neonate, 2/2 increased circ hormones

15

Supernumerary nipples (polythelia)

Occur along mammary line

Assoc w/ renal and cardiovascular anomalies

16

Poland syndrome

Amastia
Pectoalis muscle aplasia
Rib deformities

Webbed fingers
Radial nerve aplasia

17

Pectus excavatum

Usually benign

Surgery for cosmetic reasons

18

Pectus carinatum

Pigeon chest

Usually benign

Surgery for cosmetic reasons

19

Most abdominal masses in newborn 2/2

Renal
- hydronephrosis
- PCKD

20

Umbilical hernias

incomplete closure of fascia of umbilical ring

Assoc w/ diastasis recti (disorder defined as a separation of the rectus abdominis muscle into right and left halves)

Usually close spontaneously by 1 yo

Surgery if persists until 3-4yo, > 2cm, causes sx, or enlarges after age 1-2years

21

Omphalocele

Herniation of peritoneum + abdominal contents into umbilical cord

Wrap bowel with sterile saline dressings + plastic wrap
Insert orogastric tube to decompress stomach
Est IV access
Surgery ASAP

22

Gastroschisis

Hernation w/o sac through abdominal wall defect to RIGHT SIDE of umbilical cord

Wrap bowel with sterile saline dressings + plastic wrap
Insert orogastric tube to decompress stomach
Est IV access
Broad spectrum Abx
Then Surgery ASAP

23

Epispadia vs Hypospadia

Epispadia - open on dorsum of shaft of penis (pee into eye)

Hypospaida = opening on ventral side of shaft of penis
- avoid circumcision so can repair with foreskin
- ventral hood seen
- chordee sometimes associated

24

When fix undescended testes?

If not descended by 1 year

Surgery to avoid sterility or malignant degeneration

25

When fix retractile testes?

Don't need to! It's just an overactive cermasteric reflex

26

Hydrocele

Collection of fluid in scrotum (tunica vaginalis)

Usually resolves by 1 yr --> if not --> surgery

Dx w/ transillumination

27

Most common hernias in kids

Inguinal (indirect)

28

Presentation of infants born to Diabetic mothers

Ruddy plethoric complexion

Large for gestation age

Hypocalcemia
Hypomagnesemia

Insulin ---| surfactant
- prone to respiratory distress

Hypertrophic cardiomyopathy

Hyperbilirubinemia

Polycythemia

Heart defects
- ASD
- VSD
- transposition
- asymmetric septal hypertrophy

29

Tx infants of diabetic mothers

Control mom's blood sugar

monitor baby, tx hypoglycemia aggressively

30

What is counted as small for gestational age/IUGR?

Birth wts below 3rd percentile for calculated gestational age

Symmetric (if all ht, wt, etc small) vs asymmetric (if only one part of body is small)

31

Factors affecting growth of fetus

Fetal
- chromosomal DO
- TORCH infections
- congenital anomalies
- insulin deficiency

Placental
- infarction
- separation
- twin twin transfusion

Maternal
- toxemia
- HTN
- malnutrition
- smoking
- EtOH

32

Which scoring system helps determine gestational age using physical and neuromuscular criteria?

Ballard scoring system

33

Onset of WD in babies for
- heroin
- methadone
- phenobarbital

Heroin = 48 hrs after birth

Methadone = several wks (higher risk seizures)

Phenobarbital = 1-2 weeks

34

Respiratory distress syndrome
- presentation
- CXR

Tachypnea
Nasal flaring
Retractions
Cyanosis

Condition peaks at 3rd day

CXR
- reticular granular pattern
- air bronchograms

35

Tx RDS

- full term baby
- steroids 48 h before delivery

36

Transient tachypnea of newborn (TTN)

Self limited

Mostly in babies after C section

O2 requirement minimal

CXR = fluid in fissure and prominent vascular markings

2/2 retained fetal lung gluid

37

Meconium aspiration syndrome

Tachypnea + hypoxia

CXR = patchy infiltrates
PTX common finding

Tx - mech ventilation, NO, extracorporeal membrane oxygenation

38

Persistent fetal circulation

Severe hypoxemia --> pulm vasoconstrict --> R to L shunting through PFO or PDA

Echo = increased pulm A pressures, shunting

Tx
- hyperventilation to avoid acidosis
- maintain O2
- NO
- ECMO

39

Diaphragmatic hernia

Ab contents into cehst --> pulmonary hypoplasia

Scaphoid abdomen _ respiratory distress

Surgery to correct

40

Neonatal jaundice 2/2

Unconj bilirubin deposits in skin

41

Physiologic jaundice vs pathologic jaundice vs breast milk jaundice

Physio
- after day 1
- 12.9-15 mg/dL unconj
- resolves 1 wk

Anything else outside of this is pathological

Breast milk
- present at 1 wk

42

Tx neonatal jaundice

Phototherapy
- isomerizes unconj bilirubin to form more easily excreted

Exchange transfusion
- remove bilirubin
- remove circulating Abs to Hgb

43

Complications of neonatal jaundice

Unconj:
- Neurotoxicity
- Kernicterus (bilirubin accumulate in gray matter)

44

Cause neonatal sepsis

Risk factors

Group B strep (#1)
Ecoli
Listeria

UTI
Chorioamniotiis
Prematurity
Prolonged rupture of membranes

45

Signs of neonatal sepsis

May not always have fever

Full fontanel palpated on PE

46

Intrapartum antimicrobial ppx if...

+ GBS at 3-37 wks

OR

Prev infant w/ invasive dz
GBS bacteruria during preggers
Prematuirty
Rupture of membranes > 18 h
Intrapartum temp > 38 C
Unknown GBS status

47

Tracheoesophageal fistula

85% are atretic + fistula between trachea + distal esophagus

Coughing / choking w/ swallowing
Polyhydramnios

Higher risk congenital heart dz (PDA, coarctation of aorta)

VACTERL association
- vertebrae
- anus
- cardio
- trachea
- esophagus
- renal
- limb buds

48

Duodenal atresia

Bilious vomiting w/ feeding

Double bubble on abdominal films

Higher risk in Trisomy 21

Tx surgery

49

Hirschsprung disease

Suspect in any newborn fail to pass meconium in 1st 24-48 hrs life

Absence of ganglion cells

Gold st dx - bx rectal mucosa --> no ganglion cell

Tx surgery

50

Necrotizing enterocolitis

#1 surgical + medical GI emergency in newborn

Related to introduction of feeds

Bloody stools
Apnea
Lethargy

Pneumatosis intestinalis on Xray pathognomonic

Tx
- medical --> stop feeds, decompress, supportive
- surgery if necrotic bowel

51

Why are tonic clonic seizures uncommon in neonates?

b/c immaturity of NS

52

#1 cause neonatal seizures

Hypoxic ischemic encephalopathy

12-24 hr present

53

More common cause of seizures in premies

Intraventricular hemorrhage
- occurs 1-3 days age

54

Maternal dz affecting baby:
- cyanotic heart dz
- hyperparathyroidism
- SLE

Cyanotic heart dz --> intrauterine growth retardation

Hyper PTH --> HYPOcalcemia

SLE --> congenital heart block

55

Maternal drugs affecting neonate
- phenobarbital
- sulfonamides

Phenobarbital --> vit K deficiency

Sulfas --> displace bilirubin from albumin

56

Maternal intake affecting babies:
- EtOH
- isotretinoin
- phenytoin
- stilbestrol
- tetracycline

EtOH --> FAS

Isotretinoin
- facial, ear anomalies
- congenital heart dz

Phenytoin
- hypoplastic nails
- typical facies
- IUGR

Stilbestrol
- vaginal adenocarcionma

Tetracycline
- enamel hypoplasia

57

Sequence of resuscitation in neonate

Position ,suction, tactile stimulation

O2

Bag valve ventilation

Chest compression

Intubation

Meds

58

How old can you be to get heimlich?

> 1 yo

< 1 yo = back blows + chest thrusts

NO BLIND FINGER SWEEPS

59

Immunological factors in breasmilk

IgA
Lactoglobulin
Maternal macrophages

60

Contraindications to breastfeeding

Active or untreated TB (can start MF 2 wks after anti-TB tx)
HIV
Syphilis
Galactosemia
Varicella < 5d earlier or 2 d after delivery

Herpes if active lesions on breast

Drugs - EtOH, nicotine, antineoplastics, ergot alkaloids, Lithium, cyclosporine, street drugs

Mastitis is OK


INFANT galactosemia

61

Cons of whole milk

Higher renal solute load --> damaging

Can provoke intolerance of whole milk protein

Increase incidence of Fe deficiency anemia

62

What should you supplement with in kids drinking goat milk?

Folate

63

Milk or soy protein induced proctocolitis

Exclusive to infants
Presents at 2-8 wks

Non-IgE mediated immuno response to dairy and/or soy proteins

Severe reflux or vomiting
+/- Painless bloody stools
+/-Eczema

Dx/Tx
- elim milk/soy from diet in mom of breastfed infants
- hydrolyzed formula in formula fed

Spontaneous resolution by year 1

64

Clubfoot (talipes equinovarus)

Equinus + varus of calcaneum and talus
varus of midfoot
Adduction of forefoot

Tx
- nonsurgical: stretch + manipulate foot, serial plaster casts
- Start ASAP
-surgery if no good results between 3-6 mo old, definitely < 12 mo

DDX:
- metatarsus adductus
- tibial torsion
- femoral anteversion

65

#1 cause congenital aplastic anemia

Fanconi anemia

66

Race tending to have above average birth weights

African american boys

67

Risk factors for fetal macrosomia

Wt > 4kg

Maternal
- advanced age
- diabetes
- excessive wt gain during preggers
- preexisting obesity
- multiparity

Fetal
- AA or hispanic
- male baby
- post term

68

Recommend csection for suspected fetal macrosomia?

No

Rate of shoulder dystocia is not different with csection and vaginal

69

Intraventricular hemorrhage

Bleeding in germinal matrix
Grades 1-4 (3 and 4 have most long term sequelae)

Mostly in:
- premature
- LBW infants

Sx:
- seizures
- cyanosis
- bulging or tense fontanel
- apnea, bradycardia

Ppx:
- transfontanel ultrasound for all newborns with predisposing risk factors

70

Hyaline membrane disease

Usually in preemies

2/2 decreased production and secretion of surfactant --> atelectasis

CXR = fine reticular granularity of lung parenchyma

Can happen right after birth

Tx
- mech ventilation
- surfactant admin

71

Transient tachypnea

Usually follows uneventful normal term vaginal delivery or C section

LUngs clear
CXR = prominent pulm vascular markings, fluid lines in fissures, overaeration, flat diaphragm, sometimes pleural fluid

72

Persistent pulmonary hypertension of the newborn

Should be suspected in all term and post term infants w/ cyanosis with or without fetal distress

Unresponsive hypoxia to 100% O2

73

Meconium aspiration syndrome

Usually in term or post-term infants

Patchy infiltrates
Coarse streaking of both lung fields
Increased AP diameter
Flattening of diaphragm

74

When should babies stop having meconium?

Day 3 of life

75

Pierre Robin Sequence

2/2 to hypoplasia of mandibular area

Tongue is posteriorly located preventing closure of posterior palatal shelves

Micognathia
Glossoptosis
Cleft soft palate

Can be a feature of other syndromes:
- edwards
- Stickler (AD, early arthritis, ocular problems)

76

Potter sequence

Bilateral renal agenesis --> incompatible with life

Hx of oligohydramnioas

Death by pulmonary hypoplasia

Potter facies:
- hypertelorism
- epicanthal folds
- low set ears
- micrognathia
- limb abnormalities

77

Fetal Alcohol syndrome

EtOH #1 teratogen to which fetus exposed

Features:
3 main facial dysmorphisms:
- small palpebral fissures
- smooth philtrum
- thin vermillion border

- growth deficiency / FTT
- MR
- irritable, hyperactive
- fine motor dysfunction
- microcephaly
- maxillary hypoplasia
- short nose

Cardiac:
- septal defects

78

Beckwith-Wiedemann Syndrome

Hemihypertrophy

Macroglossia
Omphalocele

Hypoglycemia
Apnea cyanosis
Feeding issues
Seizures

Wilms tumor common

Route US and a-fetoprotein should be performed 6 mo - 6 yo

Survivors of infancy do ok

79

Sotos syndrome

Rare genetic DO

Excessive growth during first 2-3 years of life

+/-
Autism
MR
Hypotonia

Tx symptomatic

Prognosis is normal life span

80

Formerly most common cause of hydrous fetalis

Rh incompatibility

Now parvovirus can do this

81

How can you figure out if baby in utero has anemia?

Blood flow through MCA can correlate with Hg status and know if in utero baby has anemia

82

Bloody vaginal discharge in neonate...what do you do?

Reassure

Infants < 3 mo can sometimes get vaginal spotting or bleeding as estrogen from mom is clearing from infant circulation

83

small gestational age infants higher risk for...

Hypoxia
Polycythemia
Hypoglycemia
Hypothermia
Hypocalcemia

84

Reason for increased risk of intraventricular hemorrhage in premie

Capillary fragility of subependymal germinal matrix adn immature autoregulation of cerebral blood flow

Screen for this with serial head US!!
- 25-50% cases asymptomatic

85

Ways to reduce incidence of intraventricular hemorrhage

Prevent preterm labor

Antenatal admin of maternal steroids

86

Physiologic jaundice

Starts day 2 of life --> age 1-2 weeks

Increased unconj bilirubin because:
- At birth, RBC is increased w/ shorter lifespan --> high Hg turnover and bili production
- bili clearance is slow at first because hepatic uridine diphosphogluconurate glucuronosyltransferase (UGT) doesn't reach adult levels until 2 yo
---> asian newborns have decreased UGT activity compared to other ethnicities
- enterhepatic recycling increased in newborns b/c sterile newborn gut can't break down bilirubin to urobilinogen for fecal excretion --> more bili resorbed and recycled until gut is colonized

87

Birth weight should be regained by age

10-14 days

Healthy infants normally lose up to 7% of BW in first 5 days of life - no tx required.

88

Prune belly syndrome

Malformation mostly in males

Lax wrinkled ab wall
dilated urinary tract
intraabdominal testicular tissue

Oligohydramnios
Congenital hip dislocation, club feet

NO genetic predisposition