Neonatology 2 – High-Risk Pregnancy & Common Neonatal Problems

High-Risk Pregnancy: Definition & Factors

• Any pregnancy in which maternal and/or fetal conditions may culminate in an adverse perinatal outcome.

• Identification may occur ante- or intrapartum.

Antepartum Factors Associated with Neonatal Depression

• Pre-term labor and delivery

• PROM (premature rupture of membranes)

• Multiple gestation

• Chronic pregnancy-induced hypertension (preeclampsia/eclampsia)

• Maternal diabetes

• Maternal substance abuse

• Vaginal bleeding, placenta previa, abruptio placentae

• Lack/late/limited prenatal care

Prenatal Disturbances

• Maternal infections: GBS, Herpes, Rubella

• ↓ Fetal activity

• Maternal anemia or Rh iso-immunization

• Oligo- / Poly-hydramnios

• Previous fetal/neonatal death

• Congenital anomalies

• Maternal systemic disease (CVS, thyroid, neurologic, SLE)

• Drug therapy: lithium, beta-blockers, $MgSO_4$

• Environmental toxins/teratogens

Intrapartum Risk Factors

• Maternal/fetal infection

• Prolapsed cord, prolonged labor, maternal sedation

• Operative/assisted delivery; breech/abnormal presentation

• Meconium-stained amniotic fluid

• PROM >18 h

• Abnormal FHR patterns

Routine/Selective Screening in High-Risk Pregnancy

• Diabetes, genetic conditions, congenital anomalies → early recognition/intervention

Pre-Term Labor (PTL)

• Onset of labor <37 weeks GA (WHO: $20−37$ weeks).

• PTL → $40−50\%$ of pre-term births; remainder from PPROM or indicated pre-term delivery.

Major Risk Factors

• Low socioeconomic status, smoking, substance abuse, poor nutrition

• Inadequate/absent prenatal care

• History of PTL/delivery, uterine/cervical anomalies (DES), myomata

• Maternal HTN, preeclampsia, diabetes

• Multiple gestation, amniotic fluid disorders, vaginal bleeding, infection

Pathogenesis (Spontaneous, Isolated PTL)

• Often occult upper‐genital-tract infection → decidual activation

• Inflammatory cytokines IL-1, IL-6, TNF-α in AF → ↑ PGE$<em>2$/PGF$</em>{2α}$ → uterine contractions & cervical ripening

Treatment

• Cervical cerclage for structural incompetence

• Tocolytics: β-mimetics (terbutaline, ritodrine), $MgSO_4$, indomethacin

• Antibiotics when infection/PPROM suspected

Preeclampsia/Eclampsia

• New-onset gestational HTN $+$ proteinuria (± edema) after $20$ wk.

• Incidence: $\approx8\%$ pregnancies; major cause perinatal M&M.

• Pathophysiology: uteroplacental ischemia, RAAS activation; exact etiology unknown.

• Predisposition: primiparity, age extremes, genetics, twins, DM, non-immune hydrops.

Maternal Management

• Definitive Rx = delivery.

• Balance fetal immaturity vs maternal status → antihypertensives, $MgSO_4$ seizure prophylaxis.

Fetal Consequences

• Prematurity → dominant driver of morbidity.

• Uteroplacental insufficiency, abruptio placentae, IUGR common.

• Curiously ↓ risk of cerebral palsy vs other causes of prematurity.

Diabetes in Pregnancy

• Types: Type 1 (absolute insulin lack), Type 2 (insulin resistance), Gestational.

• Modified White Classification: A1 = diet controlled; A2 = insulin required.

• Gestational DM accounts for $80−90\%$ of diabetic pregnancies (total prevalence $3−5\%$).

• Mechanism: normal $\approx60\%$ ↓ insulin sensitivity; some women cannot compensate.

Screening & Targets

• Screen $24−28$ wk GA.

• Maintain glucose $60−120$ mg/dL → marked ↓ fetal/neonatal complications.

Fetal-Neonatal Complications

A. Congenital anomalies (Type 1): sacral agenesis, NTD, cardiac (TGA, VSD, hypertrophic CMP).
B. Macrosomia: $25−45\%$ incidence → birth trauma, asphyxia, neonatal hypoglycemia.
C. Polyhydramnios.
D. Hypoxia → polycythemia.
E. Delayed lung maturation → ↑ RDS.

Neonatal Management

• Screen/tx hypoglycemia, assess trauma, look for respiratory distress (TTNB, RDS).

Maternal Substance Abuse

• Present in $5−6\%$ pregnancies; often co-morbid with STIs, TB, hepatitis, malnutrition.

Agents & Outcomes

• Alcohol → FAS: microcephaly, MR, facial dysmorphisms, cardiac defects; withdrawal rare.

• Heroin → stillbirth, pre-term, SGA; NAS in $50−75\%$ within $48$ h: irritability, tremor, seizures.

• Methadone → later onset, more severe NAS; seizures; naloxone contraindicated.

• Cocaine → stillbirth, asphyxia, prematurity, LBW; breastfeeding contra-indicated.

• Amphetamine/Meth → ↑ mortality, prematurity, CNS bleeds.

• Marijuana → no consistent neonatal pattern to date.

Prematurity & Low-Birth-Weight (LBW)

• Prematurity: birth <37 wk.

• LBW <2500 g; VLBW <1500 g; ELBW <1000 g.

• Global prematurity rate $6−10\%$.

Contributing Factors

Maternal: low SES, preeclampsia, infection (UTI, GBS), chronic illness, drugs.
Fetal: twins, distress, anomalies.
Obstetric: cervical insufficiency, polyhydramnios, chorioamnionitis, PROM, previa, abruption.

Transition Challenges

• Immature organs, low mass → slower adaptation, low Apgar, resuscitation needs.

• Thermoregulation: large SA/BW, ↓ brown & subQ fat, immature hypothalamus; prevent via radiant warmer, wrap, minimize evaporative loss.

• Heat loss modes: conduction, convection, radiation, evaporation.

• Neutral thermal environment essential until $\ge34$ wk PCA.

Brown Fat

• Highly thermogenic; located neck, axillae, kidneys, mediastinum; absent/low in preterms.

Glucose Homeostasis

• Limited glycogen & immature counter-regulation → IV glucose or early enteral feeds.

Respiratory System

• Surfactant deficiency → RDS; apnea of prematurity (<$34$ wk) d/t immature medulla.

• ROP risk when born <32 wk (retinal vascularization incomplete).

GI/Nutrition

• Enzymes present, but motility weak; require $120−150$ kcal/kg/d$ by DOL 7−10$.</p></li><li><p>Combined parenteral + enteral (10–20 mL/kg/d increments) using breast milk or pre-term formulas.</p></li></ul><h5 id="2120c809-fc25-4a3a-bb24-638d5de3fbf6" data-toc-id="2120c809-fc25-4a3a-bb24-638d5de3fbf6" collapsed="false" seolevelmigrated="true">Hepatic/Bilirubin</h5><ul><li><p>Larger RBC mass, shorter lifespan, low UGT activity → physiologic jaundice earlier (day$1−2$), peaks$5−7$d, resolves ≤$14$d.</p></li></ul><h5 id="10a64599-5276-4f2e-96a5-4e98cddb7c71" data-toc-id="10a64599-5276-4f2e-96a5-4e98cddb7c71" collapsed="false" seolevelmigrated="true">Cardiovascular</h5><ul><li><p>PDA common; closure inversely related to GA.</p></li></ul><h5 id="27a35dfa-03be-41ed-9e46-065275b581ae" data-toc-id="27a35dfa-03be-41ed-9e46-065275b581ae" collapsed="false" seolevelmigrated="true">Immunology</h5><ul><li><p>IgG transfer mainly 3rd trimester → diminished passive immunity → ↑ sepsis risk.</p></li></ul><h5 id="93a1c87b-1d74-48fe-98e3-81af615c0497" data-toc-id="93a1c87b-1d74-48fe-98e3-81af615c0497" collapsed="false" seolevelmigrated="true">Hematology</h5><ul><li><p>Anemia of prematurity at$6−12$wk; lower iron stores.</p></li></ul><h5 id="77fb74e9-6456-4c6d-89f8-892ede601d65" data-toc-id="77fb74e9-6456-4c6d-89f8-892ede601d65" collapsed="false" seolevelmigrated="true">Survival (Developed Countries)</h5><ul><li><p>$<500$g:$15\%$;$500−750$g:$60\%$;$1250−1500$g:$>90\%$.</p></li></ul><h3 id="e15806be-3c18-4495-8511-6ab9b0d51e4c" data-toc-id="e15806be-3c18-4495-8511-6ab9b0d51e4c" collapsed="false" seolevelmigrated="true">Size-for-Gestational-Age Categories</h3><ul><li><p>SGA: BW$<10^{th}$percentile. • Early symmetric (insult$<28 wk): small HC & length; causes – severe maternal vascular disease, renal disease, anomalies, infection, chromosomal issues. • Late asymmetric (insult >28$wk): head-sparing; seen with twins, pre-eclampsia.</p></li><li><p>LGA: BW$>90^{th}$percentile; risk groups – IDM, post-dates, Beckwith-Wiedemann; macrosomia$>4 kg.

Delivery Room Management & Apgar

• Suction nose/mouth after head; clamp cord at table level; place under warmer.

• Tactile stimulation (back rub, foot flick) if needed.

Apgar Scoring

• 5 parameters (Color, Respiration, HR, Reflex, Tone) 0−2$each; assess$1 & 5$min (±$(10,15)$).</p></li><li><p>Scores:$8−10$normal;$4−7$need support;$0−3$immediate resus.</p></li><li><p>Not predictive of long-term neuro-outcome; never delay resus for scoring.</p></li></ul><h3 id="39ede6ac-7c90-4267-a72f-6a702a1392bb" data-toc-id="39ede6ac-7c90-4267-a72f-6a702a1392bb" collapsed="false" seolevelmigrated="true">Neonatal Resuscitation Principles</h3><ul><li><p>Anticipation:$10\%$need assistance;$<1\%$require extensive measures.</p></li><li><p>Goals: thermal control, airway/breathing, oxygenation, circulation.</p></li><li><p>Initial FiO$_2$: term$21\%$, pre-term$21−30\%$.</p></li></ul><h5 id="22ab1cba-5ecf-4b7c-8834-f51205024ed1" data-toc-id="22ab1cba-5ecf-4b7c-8834-f51205024ed1" collapsed="false" seolevelmigrated="true">Algorithm</h5><ol><li><p>Spontaneous breath, HR$>100$, pink → tactile stimulation.</p></li><li><p>Spontaneous, HR$>100$, cyanotic → blow-by O$_2$.</p></li><li><p>Apnoea or HR$<100$→ bag-mask ventilation.</p></li><li><p>HR$<100$despite ventilation → assess technique, ↑ FiO$_2$to$100\%$, intubate ± drugs/volume.</p></li></ol><h3 id="28528aaa-9273-43e8-9b08-6bc08c1d6dea" data-toc-id="28528aaa-9273-43e8-9b08-6bc08c1d6dea" collapsed="false" seolevelmigrated="true">Neonatal Sepsis</h3><ul><li><p>Systemic bacterial infection; incidence$1−5/1000$live births; VLBW higher.</p></li><li><p>Early-onset (EOS)$<72$h (usually$<24$h): GBS, E. coli, Klebsiella, Listeria; fulminant.</p></li><li><p>Late-onset (LOS)$>72$h to$90$d: community vs NICU; Gram-negatives (Klebsiella, Enterobacter, Pseudomonas), MRSA, CONS.</p></li></ul><h4 id="09e3d79d-cd0a-40fa-a905-e0a4d4e9d6db" data-toc-id="09e3d79d-cd0a-40fa-a905-e0a4d4e9d6db" collapsed="false" seolevelmigrated="true">Risk Factors</h4><ul><li><p>Asphyxia, prematurity, PROM$>18$h, chorioamnionitis, foul liquor, maternal fever, invasive lines.</p></li></ul><h4 id="504486b4-a122-4664-94cd-3b2f80b44b28" data-toc-id="504486b4-a122-4664-94cd-3b2f80b44b28" collapsed="false" seolevelmigrated="true">Clinical Signs</h4><ul><li><p>Subtle: feeding change, behavior; later – lethargy, temp instability, apnea, pallor.</p></li><li><p>Meningitis clues: seizures, bulging fontanel, high-pitched cry.</p></li></ul><h4 id="c7858167-eb6b-4a88-9fab-91a932795d26" data-toc-id="c7858167-eb6b-4a88-9fab-91a932795d26" collapsed="false" seolevelmigrated="true">Work-up</h4><ul><li><p>CBC, CRP, PCT, blood culture, CSF, CXR, urine; gastric aspirate shake-test.</p></li></ul><h4 id="1e5496e1-6ed8-4eb0-8be2-879bae3f279e" data-toc-id="1e5496e1-6ed8-4eb0-8be2-879bae3f279e" collapsed="false" seolevelmigrated="true">Management</h4><ul><li><p>Empiric: Ampicillin$100−200$mg/kg/d$+$Gentamicin$5$mg/kg/d.</p></li><li><p>Meningitis: double β-lactam dose; 2nd-line cefotaxime$25$mg/kg Q8–12 h or ceftriaxone$50$mg/kg.</p></li><li><p>Duration: suspected$7$d; culture-proven$14$d; G-neg meningitis$21$d; bone/joint$4−6$wk.</p></li></ul><h4 id="27dba456-7bac-4d66-babe-d67a9a35af21" data-toc-id="27dba456-7bac-4d66-babe-d67a9a35af21" collapsed="false" seolevelmigrated="true">Prevention</h4><ul><li><p>Universal precautions, hand hygiene, NICU sanitation, restrict ill staff.</p></li></ul><h3 id="139ab577-2d9a-44aa-8505-8d6fcaf0b81b" data-toc-id="139ab577-2d9a-44aa-8505-8d6fcaf0b81b" collapsed="false" seolevelmigrated="true">TORCH-ES Infections</h3><ul><li><p>Commonly acquired$1^{st}/2^{nd}$trimester → IUGR.</p></li></ul><h4 id="9d830a6a-c926-403d-b478-7495f92fcc2b" data-toc-id="9d830a6a-c926-403d-b478-7495f92fcc2b" collapsed="false" seolevelmigrated="true">Toxoplasmosis</h4><ul><li><p>Source: undercooked meat, cat feces.</p></li><li><p>Findings: jaundice, HSM, microcephaly, chorioretinitis, hydrocephalus, IC calcifications.</p></li><li><p>Tx: Maternal spiramycin; neonatal pyrimethamine$+$sulfadiazine$+$leucovorin.</p></li></ul><h4 id="6597f2d2-d492-448e-8907-544fac932b2d" data-toc-id="6597f2d2-d492-448e-8907-544fac932b2d" collapsed="false" seolevelmigrated="true">Congenital Rubella</h4><ul><li><p>Infection$<8 wk GA.

• Triad: PDA/PS, cataracts, deafness; blueberry-muffin rash.

CMV

• Primary > reactivation severity.

• Findings: HSM, jaundice, periventricular calcifications, microcephaly, thrombocytopenia.

HSV

• Manifestations: skin-eye-mouth (5-14 d), CNS (3-4 wk), disseminated (5-7 d).

• Tx: IV acyclovir; C-section if active lesions.

Syphilis

• Early: snuffles, rash, periostitis; Late: Hutchinson teeth, saber shins.

• Dx: VDRL, FTA-ABS; Tx: penicillin.

Varicella

• Neonatal if maternal rash −5 to +2 d → give VZIG; congenital limb/scar defects if infection 1st/2nd trimester.

Hypothermia in Neonates

• Skin <36.5 °C & core <35.5$°C.</p></li><li><p>Heat loss: convection, conduction, radiation, evaporation (largest at birth).</p></li><li><p>Heat production: muscle activity, non-shivering thermogenesis (brown fat).</p></li><li><p>Hypothermia stages: mild$36−36.4$°C, moderate$32−35.9$°C, severe$<32 °C.

• Warm chain: immediate drying, warm resus, skin-to-skin, early breastfeeding, warm transport.

• Management: KMC, radiant warmer, incubator; beware hyperthermia.

Respiratory Distress & Apnea

• Distress if ANY: RR >60 bpm, retractions, grunting, central cyanosis.

Etiologies

Pulmonary: RDS, MAS, TTNB, pneumonia, BPD, pulmonary hemorrhage.
Extra-pulmonary: CHD, metabolic (hypoglycemia, acidosis), neuro (seizure, IVH), anemia.

Approach

• History (GA, steroids, IDM, PROM, labor details).

• Exam (vitals, meconium, chest shape, scaphoid abdomen, nasal patency).

• Investigations: CBC, CXR, septic screen, ABG.

• Management: thermoneutrality, oxygen/CPAP/ventilation, treat cause.

Respiratory Distress Syndrome (HMD)

• Surfactant deficiency; risk ↑ with ↓ GA (<34$wk), IDM, male, 2nd twin, C-section.</p></li><li><p>CXR: low volume, ground-glass, air bronchograms.</p></li><li><p>Rx: CPAP, exogenous surfactant, gentle ventilation; prevent with antenatal steroids.</p></li></ul><h4 id="b99b76f4-be18-4ff6-82a5-701f4968fa40" data-toc-id="b99b76f4-be18-4ff6-82a5-701f4968fa40" collapsed="false" seolevelmigrated="true">TTNB</h4><ul><li><p>Delayed fetal lung-fluid clearance; term C-section or precipitous delivery; CXR: wet lungs, fissure fluid; resolves$<72$h.</p></li></ul><h4 id="d2df86cc-0726-4222-a91b-08e3d14967fe" data-toc-id="d2df86cc-0726-4222-a91b-08e3d14967fe" collapsed="false" seolevelmigrated="true">Meconium Aspiration Syndrome</h4><ul><li><p>Occurs in$5\% of meconium-stained deliveries; risk in post-dates, placental dysfunction.

• Pathophys: airway obstruction, chemical pneumonitis.

• Prevention: avoid fetal hypoxia; tracheal suction only if depressed & thick MEC.

Congenital Diaphragmatic Hernia

• Bowel in thorax → pulmonary hypoplasia; scaphoid abdomen; intubate immediately, surgical repair when stable.

Apnea of Prematurity

• Central, obstructive, mixed; ↑ incidence with ↓ GA.

• Treat underlying cause, caffeine or aminophylline, CPAP/ventilation.

Perinatal Asphyxia & Hypoxic-Ischemic Encephalopathy (HIE)

• Impaired gas exchange → fetal acidosis, hypoxemia, hypercarbia.

• Incidence 1−1.5\% live births; higher in <36$wk.</p></li></ul><h4 id="f630ad37-41a1-403f-9618-e1a06e7eab7b" data-toc-id="f630ad37-41a1-403f-9618-e1a06e7eab7b" collapsed="false" seolevelmigrated="true">Timing</h4><ul><li><p>Antepartum (placental insufficiency), intrapartum (cord prolapse, abruption), post-natal (PPHN, shock).</p></li></ul><h4 id="4ae20ffe-60e2-4953-8828-318cd22c4a94" data-toc-id="4ae20ffe-60e2-4953-8828-318cd22c4a94" collapsed="false" seolevelmigrated="true">Pathophysiology</h4><ul><li><p>Primary apnea → responds to O$_2$/stim; secondary apnea → needs PPV.</p></li><li><p>Diving reflex: blood to heart/brain → multiorgan ischemia (kidney$50\%$, CNS$28\%$, CVS$25\%$, lungs$23\%).

Diagnosis

• Prolonged acidosis, FHR <60, Apgar <3$at$10$min, seizures$<24$h, EEG abnormalities.</p></li></ul><h4 id="b586d2aa-ba19-43cc-a566-659164b2bdb8" data-toc-id="b586d2aa-ba19-43cc-a566-659164b2bdb8" collapsed="false" seolevelmigrated="true">Sarnat Staging</h4><ul><li><p>Stage I (mild): hyperalert; good prognosis.</p></li><li><p>Stage II (mod): lethargy, hypotonia, seizures;$\approx80\%$normal.</p></li><li><p>Stage III (severe): coma, flaccid, absent reflexes;$50\%$death,$50\%$major deficits.</p></li></ul><h4 id="2455b28c-2704-404f-ad24-201977102045" data-toc-id="2455b28c-2704-404f-ad24-201977102045" collapsed="false" seolevelmigrated="true">Management</h4><ul><li><p>Anticipate; avoid BP fluctuations; restrict IVF$\tfrac23$maintenance; correct acidosis; control seizures (phenobarbital first-line).</p></li><li><p>Therapeutic hypothermia (selective head or whole body$33−34$°C ×$72$h) – only proven neuroprotection.</p></li><li><p>Prevention: quality antenatal surveillance, intrapartum monitoring, timely resuscitation.</p></li></ul><h3 id="5f52a1fe-fb02-415f-8711-e5c9bc313965" data-toc-id="5f52a1fe-fb02-415f-8711-e5c9bc313965" collapsed="false" seolevelmigrated="true">Neonatal Seizures</h3><ul><li><p>Occur in$\le50\%$of HIE survivors; indicate moderate-severe encephalopathy.</p></li></ul><h4 id="467d0efd-177c-48d7-ab8d-d84b90eabd55" data-toc-id="467d0efd-177c-48d7-ab8d-d84b90eabd55" collapsed="false" seolevelmigrated="true">Types</h4><ol><li><p>Subtle (ocular deviation, chewing). 2. Clonic. 3. Tonic. 4. Myoclonic. 5. Spasms.</p></li></ol><h4 id="d92ecd48-bdfe-4787-97fe-852d76af657a" data-toc-id="d92ecd48-bdfe-4787-97fe-852d76af657a" collapsed="false" seolevelmigrated="true">Causes by Age</h4><p>Day$1−4$: HIE, IVH, metabolic, drug toxicity.<br>Day$4−14$: infection, metab, benign familial convulsion, kernicterus.<br>Week$2−8: infection, trauma, cortical malformations.

  Diagnosis & Tx

  • EEG gold standard. Labs: glucose, Ca^{2+}$, Mg$^{2+}$, Na$^+$.</p></li><li><p>First-line phenobarbital$20$mg/kg (up to$40$mg/kg). If refractory → phenytoin$15−20$mg/kg (rate$0.5−1$mg/kg/min). Benzos (lorazepam) for acute control.</p></li><li><p>Discontinue AEDs if seizure-free$>2−3 mo & etiology benign; individualize.

  Neonatal Jaundice

  • Visible when scleral >20 mg/dL or skin >5$mg/dL.</p></li><li><p>Occurs in$60\% term & 80\%$pre-term; significant in$6\% term.

  Physiology

  • ↑ RBC mass & turnover; immature ligandin & UDP-GT; sterile gut ↑ β-glucuronidase.

  • Term: peak 5−6$mg/dL on DOL$2−4$; resolves by DOL$5−7$.</p></li><li><p>Preterm: peak$8−12$mg/dL on DOL$4−7$; resolves by DOL$<10$.</p></li></ul><h4 id="bd1b8111-8be7-479c-a100-1d2e2ad92032" data-toc-id="bd1b8111-8be7-479c-a100-1d2e2ad92032" collapsed="false" seolevelmigrated="true">Breast-Feeding Jaundice (early)</h4><ul><li><p>↓ intake, dehydration; onset within first week; manage by frequent feeding.</p></li></ul><h4 id="92ea6b06-a4f1-47c2-b469-0380e27a72bb" data-toc-id="92ea6b06-a4f1-47c2-b469-0380e27a72bb" collapsed="false" seolevelmigrated="true">Breast-Milk Jaundice (late)</h4><ul><li><p>β-glucuronidase in milk; onset after week 1; may reach$10−30$mg/dL; temporary interruption$2−3$d if needed.</p></li></ul><h4 id="f323e8c1-ae64-4623-9357-fb4955d54da9" data-toc-id="f323e8c1-ae64-4623-9357-fb4955d54da9" collapsed="false" seolevelmigrated="true">Pathologic Indicators</h4><ul><li><p>Onset$<24$h, rise$>5 mg/dL/day, TSB >12$mg/dL$ (term) $/$>15$mg/dL$ (preterm), conjugated >$1.5$ mg/dL or >20\% of TSB, duration >$1$ wk (term) or $2$ wk (preterm).

  Hemolytic Disease

  • Rh(D) (severe) vs ABO (common, mild). Direct Coombs +. Treat with phototherapy, exchange transfusion if criteria met.

  Treatment Modalities

  • Phototherapy: blue-green light converts bilirubin to lumirubin & polar photoisomers → renal excretion. Initiate earlier in <35 wk or BW <2 kg.

  • Exchange transfusion: double-volume $170$ mL/kg when TSB exceeds thresholds despite intensive phototherapy or with hydrops/falling Hb.

  Complications of Exchange

  • Metabolic (hypoCa$^{2+}$, hypoMg$^{2+}$, hyperK$^+$, hypoglycemia), NEC, infection, arrhythmia.

  Kernicterus

  • Bilirubin deposition in basal ganglia, hippocampus, sub-thalamus, cerebellum.

  • Risk factors: prematurity, acidosis, hypoxia, hypoglycemia, hypoalbuminemia, sepsis.

  • Stages: I (lethargy, poor suck), II (opisthotonus, seizures), III (spasticity ↓), IV (long-term – CP, hearing loss).

  Birth Injuries

  Intracranial

  • Preterm: IVH; Term: subdural hemorrhage.

  • Manifestations: RD, pallor, seizures, unequal pupils → CT/US.

  Spinal Cord

  • Difficult delivery; complete vs partial transection vs compression.

  Peripheral Nerves

  • Brachial plexus: Erb (C$5−6$) absent Moro, waiter's-tip; Klumpke (C$7−T1$) hand paralysis ± Horner.

  • Phrenic (C$4$) → diaphragmatic paralysis.

  • Facial (CN VII) palsy from forceps.

  Skeletal/Visceral

  • Clavicle fracture esp with shoulder dystocia; manage with immobilization.

  • Liver laceration & bleed in breech.

  GI: Necrotizing Enterocolitis (NEC)

  • Prematurity largest risk; bowel ischemia + bacterial invasion → transmural necrosis.

  • S/S: feeding intolerance, abdominal distention, bloody stools, apnea.

  • XR: pneumatosis intestinalis, fixed loops, portal venous gas, free air.

  • Tx: NPO, NG decompression, IV fluids, broad antibiotics; surgery for perforation/necrosis.

  • Sequelae: strictures, malabsorption, SBS.

  Hematologic Disorders

  Anemia

  • Causes: hemolysis, acute blood loss, nutritional deficiency.

  • Tx: PRBC $10$ mL/kg, vit K (HDN), vit E/iron, EPO if indicated.

  Polycythemia (Hct >65\%)

  • Causes: placental insufficiency (SGA), delayed cord clamping, twin-twin or maternal-fetal transfusion, CAH, IDM.

  • Symptoms: lethargy, poor feeding, cyanosis, RD.

  • Complications: hyperbili, thrombosis, PPHN.

  • Tx: partial exchange transfusion.

  Endocrine Disorders

  Infant of Diabetic Mother (IDM)

  • Fetal hyperinsulinism → macrosomia (spares brain), plethoric, hypoglycemia (tremor, apnea), polycythemia, hypocalcemia, RDS.

  • Cardiac: asymmetric septal hypertrophy, VSD, TGA.

  • Tx: early feeds, D$10$W $2$ mL/kg bolus if glucose low.

  Congenital Hypothyroidism

  • Large fontanel, macroglossia, umbilical hernia, prolonged jaundice.

  • Screen T4 & TSH; treat with levothyroxine $5−10$ µg/kg/d.

  Congenital Adrenal Hyperplasia (CAH)

  • Autosomal recessive enzyme defects (mostly 21-hydroxylase).

  • Classic salt-wasting (70-75$\%$): crisis at <2 wk (↓Na$^+$, ↑K$^+$, shock).

  • Simple virilizing: androgen excess without salt loss.

  • Nonclassic: late onset (hirsutism, early puberty).

  • Females: ambiguous genitalia; males often normal externally.

  • Dx: ↑ 17-OH-progesterone (newborn screen), electrolytes, ACTH, androgens, karyotype, pelvic US.

  • Tx: hydrocortisone, fludrocortisone & Na$^+$ supp (salt-losers), surgical correction of genitalia.

  Hypothermia Management Methods

  1. Kangaroo Mother Care (skin-to-skin).

  2. Radiant warmer (servo control).

  3. Incubator (humidified warm air).

  • Monitor for hyperthermia, hidden infection, dehydration.

  Key Numerical & Formula References (LaTeX)

  • Phototherapy initiation threshold depends on GA & risk: e.g., TSB > (5 + 5 \times \text{day})\,\text{mg/dL} (illustrative—follow unit protocols).

  • Exchange transfusion volume: $V = 2 \times BW_{kg} \times 85\,mL$ (double-volume).

  • Glucose infusion rate goal in preterm: $4−6\,mg\,kg^{-1}\,min^{-1}$.

  Ethical & Practical Connections

  • Balancing maternal vs fetal indications for delivery (preeclampsia, diabetes) highlights autonomy vs beneficence.

  • Use of antenatal steroids and delayed cord clamping shows evidence-based practice evolution.

  • Resource-limited settings: warm chain, infection prevention, and WHO Essential Newborn Care strategies reduce mortality without high tech.

  Cross-Lecture Links & Real-World Relevance

  • Immunology of prematurity ties into vaccine scheduling & infection prophylaxis.

  • HIE management integrates neurophysiology (cooling) with long-term neuro-developmental follow-up.

  • Jaundice management overlaps with pharmacology (drug displacement of bilirubin) and genetics (G6PD deficiency prevalence in certain populations).

  Summary Checklist for Exams

  • Define high-risk pregnancy and list ante-/intrapartum factors.

  • Recall surfactant physiology, RDS CXR, and therapy.

  • Calculate Apgar, interpret, and outline NRP steps.

  • Distinguish EOS vs LOS sepsis organisms & treatment durations.

  • Identify Sarnat stages and management of HIE including hypothermia window.

  • Apply TSB thresholds for phototherapy/exchange in term vs pre-term.

  • Recognize ambiguous genitalia algorithm and CAH management.

  • List NEC radiographic signs and initial management bundle.

  End of comprehensive study notes.