Prematurity

Question 1

What counts as premature?

Answer 1

born before 36 wks

Question 2

What is low birth weight?

Answer 2

birth weight <2.5kg

regardless of gestational age (50% are pretern)

(norm = 2.5-4.5kg)

Question 3

What weights cound as very low birth weight and extremely low birth weight?

Answer 3

VLBW = <1.5kg regardless of age

ELBW = <1kg regardless of age

Question 4

What may cause prematurity (risk factors)?

Answer 4

• Cervical incompetence
• intrauterine stretch
• intrauterine bleeding
• maternal medical conditions
• foetus
• trauma
• PMhx preterm birth
• SMOKING”

Question 5

What can cause intrauterine stretch making it a RF for prematurity?

Answer 5

• multiple foetueses
• polyhydramnios
• uterine abnormality

Question 6

What can cause intrauterine infection making it a RF for prematurity?

Answer 6

• chorioamnionitis
• bacterial vaginitis

Question 7

What can cause intrauterine bleeding making it a RF for prematurity?

Answer 7

Abruption

APH (bleeding from or into the genital tract occuring from 24+0 weeks of pregnancy)

Question 8

What can cause maternal medical conditions are a RF for prematurity?

Answer 8

PET or HTN

pyelonephritis

Question 9

What can cause foetal conditions are a RF for prematurity?

Answer 9

congenital malformations

IUGR

Question 10

What can trauma is a RF for prematurity?

Answer 10

where emergency section is indicated e.g. PROM

Question 11

What general care problems can prematurity cause?

Rx?

Answer 11

• hypothermia from:
• large surface area:mass ratio,
• thin skin &
• little subcut fat

hypothermia leads to increased energy consumption –> hypoxia, hypoglycaemia, failure to thrive & death

• incubator/radiant heaters!

Question 12

Respiratory distress syndrome

pneumothorax

apnoea, bradycardia and desaturation episodes

are all what?

Answer 12

problems / complications of prematurity

Question 13

when a baby takes their first breath there is supposed to be a fall in pulmonary vascular resistance

if this doesnt happen what conditon does it result in?

Answer 13

-> pulmonary HTN!

this interrruption of normal fall in pulm vasc resistance w/1st reath is can be due to:

• meconium aspiration
• pneumonia
• RDS
• diaphragmatic hernia
• GBS infection
• pulmonary hypoplasia

Question 14

You suspect pulmonary hypertension in a neonate.

What test do you (Ix) do and what would it show?

Answer 14

Echo

• shows R–>L shunting (cyanotic, due to high pressure) at ductus arteriosis
• IN ABSENCE of structural heart disease

Question 15

What is ECMO?

Answer 15

• Extra-corporeal membrane oxygenation - complex procedure available in 3o units - can be used in pulmonary HTN
• Providing life support for respiratory failure (&cardiac)
• • for those whose heart and lungs are unable to provide adequete life sustatining gas exchange
• obviates the need for lung gas exchange

Question 16

What are very low birth weight babies particularly at risk of? [VLBW = <1.5kg regardless of age[

Answer 16

Apnoea / desaturation

Question 17

This neonatal condition can be spontaneous or have an underlying cause including:

• infection,
• hypoxia,
• anaemia,
• electrolyte disturbance,
• hypoglycaemia,
• seizures,
• heart failure,
• aspiration due to GORD

what condition is it? & Rx?

Answer 17

Apnoea / desaturation

Prevention: maternal corticosteroids (23-34wks gestation)

management is that it is mostly self limiting, if not:

1. Airway: Check airway
2. Breathing:
   
   • Gentle tactile stimulation
   • CPAP
   • Methylxanthine e.g. caffeine (used in babies <28wks to stim breathing)
   • Mechanical ventilation if the above do not succeed

Question 18

A CXR of a neonate shows areas of opacification and cystic chenge also hyperinflation and radiolucent areas alternanting with thin, denser lines.

What condition is this related to & its Rx?

Answer 18

its is bronchopulmonary dysplasia caused by pressure & volume trauma from artificial ventilation, O2 toxicity & infection.

The neonate is @ risk of developing chest infections

–> Rx: give monoclonal abtibody to RSV (commonest cause of bronchiolitis)!

Question 19

What do patent ductus arteriosus and shock represent regarding newborn conditions?

Answer 19

PDA and shock are both cardiac problems/complications of prematurity

Question 20

A neonate has raised HR, low BP, low UO & is in a coma. What is this?

What could have caused it?

Answer 20

SHOCK!

• Blood loss
  
  • placental haemorrhage, Twin-twin transfusion, intraventricular haemorrhage, lung haemorrhage
• capillary plasma leaks
  
  • sepsis, hypoxis, acidosis, necrotising enterocolitis,
• fluid loss
  
  • D&V, inappropriate diuresis
• cardiac causes
  
  • hypoxia, L-R shunts, valve disease, coarctation

Question 21

a neonate is vomiting, has distended abdomen, blood in stools and appears septic/shock

What could be causing this and why?

Answer 21

Necrotising enterocolitis

younger gest. age = more likely to have this

possible causes =

• bowel infection,
• milk feeds (6x greater risk compared to breast milk),
• hypoxia-ischaemia of bowel

Question 22

an AXR of a neonate shows:

distended bowel loops,

thickened bowel walls,

intramural gas & air in portal tract

what condition is this? & its complications?

Answer 22

necrotising enterocolitis

short term complications:

• necrosis & bowel perforation
  
  • will see air under diaphragm on AXR if bowel perforation

long term complicatons:

• malabsorption & strictures (25% mortality!)

Question 23

How do you manage neonatal shock?

Answer 23

• ABCDE,
• colloid 10-20mL/kg IV as needed,
• inotropies e.g. Dopamine, dobutamine

Question 24

How do you Rx necrotisin enterocolitis?

Answer 24

• ABC support
• Broad spectrum abx
• parenteral nutrition (as gut isnt functioning!)
• surgical correction if bowel perforates

Question 25

What do the following conditions relate to? * Jaundice * Cholestatic obstructive jaundice * Acute renal failure

Answer 25

renal/liver complications of prematurity

Question 26

What do the following conditions relate to? * Hypoglycaemia * Electrolyte abnormalities * Osteopenia

Answer 26

metabolic conditions/complications of prematurity

Question 27

A premature neonate presents with visual loss what condition causes this and what is the management?

Answer 27

retinal detachment caused by abnormal fibrovascular proliferation of retinal vessel = retinopathy of prematurity RF: premature, low birt weight (\<2.5Kg), supplemental oxygen especially with large fluctuations in PaO2 Rx: diode laser therapy (causes less myopia (short sightedness) than cryotherapy

Question 28

A baby is born at \<27wks old when should they be screened for retinopathy of prematurity using indirect opthamoscopy? if they were born at 27-32 weeks when should they be screened using indirect opthalmoscopy?

Answer 28

~4 weeks after both times * so if \< 27 wks do it at 20-31 wks age * if 27-32 wks do the check at 28-35 days of life --\> repeat 2 weekly depending on severity of disease

Question 29

* sensorineural hearing loss * retinopathy are related to what?

Answer 29

vision and hearing impact of prematurity

Question 30

* Neurodevelopmental problems - cognitive delay, seizures, education difficulties, behavioural problems, cerebral palsy * Hydrocephalus * intraventricular haemorrhage * hypoxic-ischemic encephalopathy * neonatal seizures are related to what?

Answer 30

neurological complications of prematurity

Question 31

* anaemia * Impaired leucocyte function * Septicaemia, meningitis * Urinary tract infection * Fungal and viral infections are related to what?

Answer 31

haematology and infection complications of prematurity + anaemia of prematurity

Question 32

How do you treat anaemia of prematurity?

Answer 32

Anaemia of prematurity - iron supplementation is required for up to **6 months to correct**

Question 33

* Parental anxiety and distress * Family relationship disruption are related to what?

Answer 33

social complicatons of prematurity

Question 34

What causes mortality in prematurity?

Answer 34

**mortality** in prematurity is mainly due to: 1. **infection** of the resp tract (from impaired leucocyte function) or 2. **brain injury**

Question 35

unsupported blood vessels in the brain and unstable BP (can get this from birth trauma & resp distress) in can cause 1/4 premature babies to have what? risk factors: include perinatal asphyxia, RDS & pneumothorax

Answer 35

_intraventricular haemorrage_ * bulging fontanelle * seizures * cerebral irritability * asymptomatic

Question 36

How do you investigate intraventricular haemorrhage in neonate?

Answer 36

* USS through fontanelle (sx: is bulging fontanelle) * MRI

Question 37

What does delayed cord clamping help prevent?

Answer 37

Intraventricular haemorrhage! complications of IBH = lower IQ, CP, hydrocephalus Rx (LP, ventricular tap, VP shunt)

Question 38

hydrocephalus is a complication of IVH. What is the Rx for hydrocephalus?

Answer 38

hydrocephalus Rx: * LP, * ventricular tap, * VP shunt

Question 39

What do you call brain injury secondary to hypoxic-ischaemic insult? and what can cause the hypoxic-ischemic insult?

Answer 39

Hypoxic-ischemic encephalopathy (HIE) can be caused antenatal, intrapartum or postpartum e.g. * cord prolapse * placental abruption * maternal hypoxia * inadequate postnatal CPR

Question 40

After placental abruption a woman gives birth to a baby who is experiencing respiratory depression, is acidotic within 24h of birth. What is this? Rx?

Answer 40

hypoxic ischaemic encaphalopathy (sx: of neonate encephalopathy - dc consciousness, seizures, difficulty maintaining and initiating respiration, depression of tone and reflexes) Rx: * resucitation, * avoid hyperthermia - therapeutic hypothermia in term babies reduces death and disability, * exclude other causes of encephalopathy, monitoring and rx of seizures.

Question 41

When do neonatal seizures commonly occur?

Answer 41

12-48hrs after birth they can be generalised, focal, tonic, clonic or myoclonus

Question 42

What do these all represent? * Hypoxic-ischaemic encephalopathy (antenatal or intrapartum hypoxia) * Infection - meningitis, encephalitis * Intracranial haemorrhage/ infarction * Structural CNS lesions - focal cortical dysphasia, tuberous sclerosis * Metabolic disturbance - hypoglycaemia, low Ca, high Na, low Mg * Metabolic disorders - urea cycle disorders, amino acid metabolism * Neonatal withdrawal from maternal drugs or substance abuse * Kernicterus * Idiopathic e.g. Being 5th day fits

Answer 42

they are all causes of neonatal seizures

Question 43

How do you diagnose neonatal seizures?

Answer 43

:there are subtle signs, TF--\> EEG can confirm seizure activity also look for cause (part of Rx for neonatal seizures) * Cerebral function analysis monitoring (CFAM) if available * US or MRI head * Toxicology screening, * serum ammonia, urine organic acid, (urea cycle disorders) * serum amino acids, (amino acid metabolism) * karyotype, * TORCH screen (neonatal infections screen)

Question 44

How do you rx neonatal seizures?

Answer 44

**_ABCDE, turn on side_** 1. Rule out reversible causes e.g. Hypoglycaemia 2. Commence empirical abx 3. IV access & bloods - FBC, U&E, LFTs, calcium, Mg, glucose, blood gas 4. Treat cause * STATUS (\>5mins) \*see notes\* * HYPOCALCAEMIA - calcium glauconite, monitor ECG * HYPOMAGNESAEMIA - MgSO4 IV

Question 45

Where should peterm babies be looked after? whats their prognosis at \>32 weeks and at 23-26wks?

Answer 45

Delivery should take place in a centre capable for caring for preterm babies Adequate resuscitation once born --\> NICU/SCBU * \>32 weeks have excellent prognosis * 23-36 weeks, babies will develop many problems & will have to remain in hospital for many weeks - overall mortality is high

Question 46

What feeding do neonates/preterm \<1.5kg need?

Answer 46

\<1.5kg = * phosphate supplementation + supplemental calories, * protein, * vit D, * calcium

Question 47

What feeding do babies \<2kg need?

Answer 47

\<2kg: **supplemental breast milk or low-birth-weight formula** *[if under \<1.5kg phosphate supplementation + supplemental calories, protein, vit D, calcium }*

Question 48

What age preterm baby needs an oro- or nasogastric tube?

Answer 48

if \<35weeks if very premature (\<30wks) = need parenteral feeding

Question 49

What monitoring does a neonate have?

Answer 49

* Vitals * Temp, * pulse, * BP (intra-arterial if critical) * respirations, * Bloods: * blood gasses, * U&E, * bilirubin, * FBC, * General * weight , * weekly Head Circumference

Question 50

Regarding the ethics of intervention in extreme premature neonates. What is considered so premature/small that it has a negligible chance of survival and with parents permission a ventilator can be switched off?

Answer 50

* **Neonate \<24wks or \<500g** has a negligible chance of survival * With parents' permission a ventilator can be switched off * *[NB: \>32weeks have excellent prognosis* *23-36weeks, babies will develop many problems & will have to remain in hospital for many weeks - overall mortality is high]*