special pops - Fetal and Neonatal

three components of newborn medical history

maternal and paternal medical and genetic history, maternal past obstetric (previous pregs) history, current antepartum and intrapartum obstetric hx

T/F: history of premature deliveries increases future risk of premature deliveries

True

Florida Power And Light

F: full term

P: premature

A: abortions

L: live births

Rhogam administered when

Rh- mom @ 28 wks

prenatal testing

ultrasound, amniocentesis, screening tests

antepartum tests

for fetal well-being --> biophysical profiles, nonstress tests, Doppler assessment of fetal blood flow

APGAR scoring

A: appearance

P: pulses

G: grimace

A: activity

R: respirations

minor anomalies are

common variants that do not influence the infant's well-being and typically do not ned to be investigated in an otherwise healthy infant

minor anomalies that do not require special investigation

preauricular pits

shallow sacral dimple withOUT cutaneous abnormality within 2.5cm of anus

cafe au lait spots ≤3 in white infant or ≤5 in african american infact

jaundice within 24 hours is

always pathologic!!

peripheral vs central cyanosis

peripheral is normal, generalized/central need immediate workup!

forms of head swelling

cephalohematoma, caput succedaneum

cephalohematoma characteristics

buildup of blood contained within suture lines, d/t pressure/trauma during delivery, resolves on its own

caput succedaneum

swelling/edema of scalp that crosses suture lines, benign and self-limited

common ocular issue in infants

subconjunctival hemorrhage d/t birth trauma, benign and self-limited

babies ≤ _______ are obligate nasal breathers

1 month`

if a baby has a tongue tie/lip tie, how do you tx?

leave them alone until they cause a problem

clavicles

fracture common d/t birth trauma

T/F: clear/white/pink vaginal discharge is normal in female infants in the first week

True

Reflexes present at birth

sucking, palmar/plantar grasp, Moro (startle)

MC cause of TRANSIENT respiratory distress in newborn

TTN

TTN pathophysiology

delayed clearance of fetal lung fluid after birth, related to hypovolemia, hypothermia, or metabolic acidosis 2/2 stressful delivery

TTN onset and resp rate

mildly elevated or normal for first hour of life

gradual increase during next 4-6 hours

peaks in 6-36 hours

gradual return to normal by 48-72 hours

tachypnea, grunting, nasal flaring, intercostal/subcostal/suprasternal retractions indicate

TTN

TTN RF

C-section without trial of labor

late-preterm delivery (34-37 wks gestation)

materal diabetes

precipitous delivery or fetal distress

maternal sedation

TTN CXR findings

good lung volumes, increased interstitial markings, perihilar streaking, fluid in fissures

(think mild interstitial edema)

TTN ABG

mild hypoxemia with or without hypercarbia

TTN tx

supportive --> oxygen, CPAP, IVF, close monitoring

abx if can't rule out other disease

preterm vs term vs postterm

preterm: ≤37 wks

term: 37-41 wks

postterm: ≤42 wks

assymetric vs symmetric SGA

asymmetric: late-pregnancy problem (Htn, placental insufficiency), better outcomes

symmetric: early problem, chromosomal abnormality, drug use, or congenital viral infection -- worse outcomes

tx important for preterm infant

thermoregulation, less body fat to regulate self!!! and nutritional support for family and pt

TPN feedings for infants

<37 wks (don't have sucking/swallowing/breathing coordination)

risk for hypoglycemia in preterm infants d/t

lack of body fat stores and decreased thermoregulation

pulmonary immaturity-surfactant deficiency

structural immaturity in infants ≤26 wks, noncompliant lungs and extremely compliant chest wall --> inefficient respiratory mechanics

sx --> apnea and bradycardia d/t patency of ductus arteriousis and compromised pulm-gas exchange d/t overperfusion and edema of lungs

more risks with prematurity

subependymal and intraventricular hemorrhage, periventricular leukomalacia (PVL)--> immature cerebral vasculature

immature renal function --> complicates fluid and electrolyte management

increased susceptibility to infection

hypoglycemia and hypocalcemia d/t immature metabolic processing

bone marrow immaturity --> anemia

incomplete vascularization of retina --> retinopathy

survival rates in the 90% range and decreased complications of prematurity

>28 wks

birth weight <1500 kg

risk of cerebral palsy, cognitive delay, and hydrocephalus

visible jaundice

TSB >6

hyperbilirubinemia

TSB >17

kernicterus

TSB >20, exchange transfusion and phototherapy to prevent it from getting this high

pathologic jaundice warning signs

jaundice at <24 hrs old

TSB increase >0.2 per hour

TSB >15 (risking getting closer to kernicterus)

causes of neonatal jaundice

increased bili production (antibody-mediated hemolysis, nonimmune hemolysis, nonhemolytic)

decreased rate of conjugation (UDPGT gene abnormalities cause enzyme deficiency/inactivity)

unknown/multiple factors --> racial, prematurity, breast feeding (breastfeeding jaundice)

MCC of SEVERE respiratory distress in the newborn

RDS

RDS pathophys

biological and biochemical immaturity --> pulmonary surfactant deficiency --> alveolar collapse at low volumes + atelectasis --> V/Q mismatch and pulmonary edema --> decreased lung compliance and altered gas exchange patterns

RDS ABG

hypoxemia, hypercarbia, and acidosis

RDS is _________ proportional to gestational age

inversely

3 multiple choice options

RDS onset

immediate or within minutes to hours

peak severity 3-4 days after birth

recovery with brisk urinary diuresis

RDS MC in infants

between 23 and 25 wks gestation

tachypnea >60 bpm, grunting, nasal flaring, suprasternal/subcostal/intercostal retractions (all same as TTN) + cyanosis

RDS

RDS maternal prevention

tocolytic agents to arrest premature labor

maternal corticosteroid tx to accelerate fetal lung maturity 24-48 hrs prior to delivery

RDS CXR

fine reticulogranular "ground glass" appearance with air bronchograms and diffuse atelectasis

RDS tx

intratracheal exogenous pulmonary surfactant!!!!

oxygen, respiratory support, IVF, electrolytes

surfactant prophylaxis

pts <29 wks gestation

when is poor feeding a red flag

almost always! if pt had a normal birth and normal apgar, they should be feeding well!

poor feeding can be a sign of

rematurity, anatomical malformations (cleft palate), sleepiness 2/2 metabolic issue (jaundice, hypoglycemia, hypothyroidism), neuro problems (Seizures, IVH, encephalopathy), infections (GBS)

hypoglycemia

glucose <40 mg/dL from birth-4 hrs

glucose <45 4-24 hrs

RF for hypoglycemia

LGA/SGA, preterm, diabetic mothers, stressed out infants

LGA

>90% wt for age (>8 lb 13 oz)

MCC of LGA

post-date delivery and diabetic mothers

delivery problems of LGA

prolonged vaginal delivery time, difficult birth, birth injury (shoulder dystocia, clavicle fx), increased risk of c section

LGA complications

hypoglycemia --> poor glucose regulation, increased birth defects, respiratory distress

SGA

<10% wt for age (<5 lbs, 8 oz)

MCC of SGA/IUGR (intrauterine growth restriction)

maternal HTN, CKD, advanced DM, cardiac/resp dz, malnutrition, anemia, infection, substance abuse, cigarette smoking

SGA uterine/placental causes

decreased blood flow in uterus and placenta, placental abruption, placenta previa, infection in tissues around fetus

SGA fetal causes

multiple gestation (twins dont grow as big), infection, birth defects, chromosomal abnormality

SGA/IUGR complications

low oxygen and APGAR score, meconium aspiration!!, hypoglycemia, polycythemia

twitching

jittery/tremulous movements, more pronounced in preterm infants, NOT concerning, easily stopped, no associated breath-holding or altered consciousness

seizure vs twitching

seizure will persist regardless of positioning and has associated breath holding or altered consciousness

irritability

excessive crying, fussinss, inability to soothe with standard techniques d/t hunger, fatigue, heat/cold, hair tourniquet (all benign) or infection, drug w/drawal, prematurity, metabolic issues (all concerning)

lethargy

state of decreaed energy/alertness, altered consciousness, limp, still and difficult to arise from sleep

lethargy causes

CNS infection, hyperbilirubinemia, anemia, heart defects, hypoxia, metabolic issues, medication exposure, intracranial hemorrhage

anemia

hct <40% at birth

anemia acute vs chronic

acute: signs of hypovolemia (tachycardia, poor perfusion, hypotension), normal reticulocyte count

chronic: pallor without hypovolemia, HIGH reticulocyte count

anemia tx

erythropoietin or transfusion in infant has signs of cardiopulmonary compromise

vitamin K deficiency occurs in

exclusively breast-fed infants but clinically well

signs of vit K deficiency

bleeding from mucous membranes, GI tract, skin, or intracranial

vit K deficiency labs

prolonged PT, relatively normal PTT, normal fibrinogen and plt count

vit k deficiency bleeding prevention

early bleeding (0-2 wks) --> parenteral or oral vit k admin

late dz (2-6 wks) --> parenteral vit k only

thrombocytopenia

generalized petechiae, oozing at cord or puncture site

<10,000-20,000 plts

thrombocytopenia in well infant

iso-immune thrombocytopenia

thrombocytopenia in sick or asphyxiated infant

disseminated intravascular coagulation

thrombocytopenia tx

plt transfusion for term infants with clinical bleeding or plt <20,000

or

preterm infants with plt <50,000

meconium

first intestinal d/c of a neonate, sterile mixture of lanugo, vernix, cellular debris, bile acids, and pigments, gastric and pancreatic secretions, mucus and blood

in utero meconium passage is associated with

antepartum or intrapartum fetal hypoxia, acidosis or both --> increased intestinal peristalsis and rectal sphincter relaxation

MAS is rare before

37 wks

meconium aspiration can lead to

partial or complete obstruction of the airways

partial meconium aspiration

air trapping, hyperinflation, increased potential for air leaks --> flattened diaphragm, barotrauma

complete meconium aspiration

alveolar collapse, atelectasis, V/Q mismatch --> secondary surfactant deficiency, decreased pulmonary compliance with resultant oxygen requirement, hypercarbia and acidosis

MAS RF

postdate gestation, fetal distress, in utero hypoxia

MAS tx

supportive!, ventilation, high frequency ventilation (HFOV), oxygen, nitric oxide (direct pulm vasodilator), intratracheal surfactant, abx

what is a nonvigorous neonate?

infant born with MSAF, depressed respirations, poor muscle tone, and/or HR <100 bpm

tx --> direct tracheal suctioning

MAS CXR

patchy pulmonary infiltrates surrounded by areas of hyperinflation

MAS + surfactant deficiency

same as MAS but may also have streaky linear densities or decreased lung volumes with heterogenous densities

neonatal pneumonia RF

prolonged rupture of membranes, maternal fever, preterm labor, prematurity, asphyxia (cord around neck, not breathing, amniotic fluid stagnates, bacteria grow)

neonatal pna s/s

inc work of breathing, tachypnea, retractions, nasal flaring, apnea and cyanosis, poss temp instability and oxygen desats

early onset pna dz (<7 days old)

in utero or perinatal acquisition --> GBS, E. coli, Klebsiella, listeria

late onset pna dz (>7 days old)

gram (-) enteric bacteria, fungal agents, chlamydia, and HSV (looks like systemic dz)

neonatal pna CXR

lung hyperinflation with coarse densities or may look just like RDS

neonatal pna tx

supportive and respiratory tx and close monitoring

bacterial --> ampicillin + (aminoglycoside OR 3rd gen ceph)

viral or fungal --> antiviral/antifungals ASAP

MCC of sepsis and meningitis BEYOND neonatal period (>1 mo)

strep pneumo and Nesseria meningitidis