When is death considered to be...

1. Perinatal mortality 
2. Neonatal mortality
3. Infant mortality

1. b/t 20wks gestation & 28 days
2. b/t birth & 28 days
3. b/t birth & 12 months

At what weight is a baby considered...

1. Low birth weight
2. Very low birth weight
3. Intrauterine growth retardation

1. <2500 grams
2. <1500 grams
3. <5th %ile for gestation

Oligohydramnios

Club feet, Compressed facies, Low-set ears, Pulmonary hypoplasia

Polyhydramnios

1. Prematurity
2. IUGR
3. Breech presentation
4. Twin-Twin transfusion

1. Twin-Twin transfusion only develops in what type of twins?
2. Donor develops...
3. Recipient develops...

1. Monozygotic twins with one placenta
2. anemia, growth retardation, oligohydramnios
3. polycythemia, plethora, polyhydramnios

Fetal Hgb replaced with adult by __ mos of age

F Hgb has higher affinity of oxygen

3-6

1. cord clamped, increasing systemic pressure
2. ductus venosus closes
3. fluid in lungs/airways resorbed
4. pulmonary vascular resistance drops as breathing initiated and oxygen tension increased
5. increased blood flow from PV to LA leads to increased LA pressure, inducing PFO closure
6. increased oxygen tension induces PDA closure

What are the ABCs of resuscitation in the delivery room?

When do you ventilate with BVM?

When do you do chest compressions?

Airway: clear airway of fluid or meconium

Breathing: if apneic/cyanotic/HR <100, ventilate w/BVM

Circulation: chest compressions if HR<60

APGAR scores

1. Normal
2. Close attention for potential pathology and need for resuscitation
3. Cardiopulmonary arrest or CNS depression

1. 8-9
2. 4-7
3. 0-3

0 - blue or pale

1 - pink body & blue extremities

2 - completely pink

0 - absent

1 - <100

2 - >100

0 - no response

1 - grimace

2 - cough or sneeze

0 - limp

1 - some flexion

2 - active movement

0 - absent

1 - slow, irregular

2 - good, crying

gestational age

Physical exam: Assess firmness of pinna, breast tissue dev't, lanugo hair, flexion of extremities, joint laxity.

>90th percentile = __

<10th percentile = __

>90 = large for gest age

<10 = small for gest age

1. Heart rate: ___
2. Resp rate: ___
3. Mean BP: ___

1. 120-160
2. 30-60
3. ~ gest age

- whitish, pinhead sized concretions found on the chin, nose, forehead, and cheeks

- present in one third of all neonates

- resolves w/in a few weeks

Milia

- may occur over entire body

- 3 stages: Pustules, Ruptured pustules, Hyperpigmented macules

Pustular melanosis

- red macules w/a central yellow-white papule

- appears at 48hrs of life, may last 7-10d

- wright stain reveals eosinophils

- benign but beware of Herpes Simplex

Erythema toxicum

During the PE, what should you check for on the...

• Face?
• Neck & Chest?
• Lungs?

• epicanthal folds, hypertelorism, preauricular tags, red reflex, cleft palate
• palpate brachial cleft cysts, thyroglossal duct cyst, fractured clavicles
• retractions, grunting, nasal flaring, breath sounds

Kidney b/c dev around same time

• palpate upper and lower extremity pulses
• auscultate for murmurs
• assess for cyanosis

PDA: continuous machine-like murmur LUSB

PPS: systolic ejection murmur LLSB radiating to back and axilla

Transposition of great vessels

• Omphalocele: herniation of abd contents into base of umb cord
• Gastroschisis: abd wall defect resulting in herniation of abd content
• masses (m/c hydronephrosis)
• assess liver, spleen
• make sure cord has 3 vessels
• assess distension - may indicate obstruction, intestinal atresia, Hirschsprung's dz

no BM w/in 24hrs of birth

What's the maneuver?

With hips abducted and fingers placed over the greater trochanter, apply inward and upward pressure

Ortolani

What's the maneuver?

With hips adducted and thumbs on inner thigh, apply outward and downward pressure

Barlow

1. prolonged labor
2. breech presentation
3. macrosomia or cephalopelvic disproportion
4. forceps or vacuum delivery

- diffuse swelling of scalp and soft tissue which extends across sutures

- d/t uterine/vaginal pressure

- resolves spontaneously

Caput succedaneum

- subperiosteal hemorrhage that never extends across suture lines, often d/t traumatic or forceps delivery

- typically resolves spontaneously but should be monitored closely (2-3wks)

- may evaluate for skull fx

- monitor for drops in hct or rise in bilirubin

Cephalohematoma

- bleeding below epicranial aponeurosis which may cross suture lines

- also often related to birth trauma

- Hct, signs of shock, signs of active bleeding should be carefully monitored

Subgaleal hematoma

Which brachial plexus injury?

1. affects C5 and C6 causing arm to be adducted, extended, and internally rotated "waiter's tip"
2. affects C7, C8, and T1 causing paralysis of wrist and grasp reflex

1. Erb palsy
2. Klumpke palsy

("E" before "K"; 5,6 before 7,8,1)

- insufficiency of pulmonary surfactant found mostly in premature infants

- deficiency leads to hypoxia and respiratory acidosis

Respiratory distress syndrome

RDS

- surfactant reduces surface tension which decreases atelectasis and improves lung compliance

- production begins in response to ____ secretion at ____ weeks

cortisol; 32-34

Lecithin:Sphingomyelin ratio. (>2:1 = mature)

b/c lecithin increases with lung maturity as sphingomyelin remains constant

reticulogranular pattern (ground glass) with peripheral air bronchograms

antenatal steroids, surfactant replacement, support with oxygen, ventilator, CPAP

- benign disease of term infants with respiratory distress shortly after delivery, typically lasting 3-5 days

- possibly related to delayed resorption of fetal lung fluid

Transient tachypnea of the newborn

C-sections, prolonged labor, maternal sedation, macrosomia

hyperexpansion, perihilar streaking, prominent pulmonary markings, fluid in minor fissure

primarily supportive: oxygen, ventilator, CPAP

What's the progression/cause of meconium aspiration syndrome?

When is it most common?

- infant passes meconium while in utero into amniotic fluid (a sign of fetal distress)

- with the infant's first breath, meconium may be aspirated inducing airway obstruction and a chemical pneumonitis

m/c in post-term infants

intubate and suction trachea prior to spontaneous respiration

Tx: support with chest PT and oxygen, ventilator, CPAP. don't stimulate

oxygen-dependent at 36 wks and characteristic clinical and radiographic findings

- oxygen dependence, compensatory metabolic alkalosis, poor growth, reactive airways in premature infants

- results from high ventilatory pressures and exposure to high concentrations of oxygen

sponge-like cystic appearance

bronchodilators, diuretics, oxygen, RSV prophylaxis, nutritional support

Where does a diaphragmatic hernia typically occur?

What does this lead to?

How does it manifest?

on the left through the Foramen of Bochdalek

pulmonary hypoplasia

respiratory distress shortly after birth

Immediate intubation and decompression.

Surgical repair and support for pulmonary hypoplasia (ECMO)

What's the definition of Apnea of Prematurity?

cessation of breathing for >20 sec related to poorly developed central control fxn

- usu resolves by 36 wks post-conception

If anemic - give RBCs

If hypoxic - provide oxygen

May treat with caffeine or theophylline

- improves diaphragmatic fxn, sensitivity to CO2, and minute ventilation

Persistent pulmonary HTN

How does persistant pulmonary HTN present?

How do you treat it?

with respiratory distress and cyanosis despite adequate ventilation

treat with resp support and nitric oxide

patent ductus arteriosus

PDA

1. As vascular resistance drops, an increase in ___ shunting is noted, leading to ___ and ___
2. Heralded by ___, ___, and ___

1. L-R; CHF and pulmonary edema
2. wide pulse pressure, bounding pulses, and continuous "machine-like" murmur

Indomethacin (inhibits prostaglandins) or surgical ligation

maternal hyperglycemia - glucose crosses placenta - fetal hyperglycemia - fetal pancreas responds - fetal hyperinsulinemia

• hypoglycemia, hypocalcemia
• macrosomia, polycythemia, hyperbilirubinemia
• caudal regression syndrome, congenital heart defect
• small left colon

__ freely crosses placenta

__ does not

IgG

IgM

IgG against platelets cross the placenta and cause neonatal thrombocytopenia

Anti-Ro & Anti-La Abs cross the placenta inducing a neonatal lupus syndrome.

most severe complication is complete heart block

RBC production:

• From 20th day gestation until last trimester, takes place in ____
• After last trimester, takes place in ____

• liver and spleen
• bone marrow

ABO incompatibility is only an issue in type-__ mothers, Why?

Type-O mothers with A, B, or AB infants because Type O mothers produce IgG.

(requires prior sensitization to form IgG which induce hemolysis)

Type A, B, & AB mothers produce IgM

What is the result of Rh incompatibility on the fetus?

Erythroblastosis fetalis

• severe in utero hemolysis
• heart failure
• fetal hydrops

Rhogam 72 hrs prior to delivery

-binds Rh+ fetal cells transfused to mom during delivery thereby preventing sensitization

fetal RBC in mother's blood after acidic buffer applied

Polycythemia

1. defined as Hct >__
2. seen in ___, ___, ___
3. results in ruddy/plethoric appearance
4. may cause ___, ___, ___, ___
5. treat with ___

1. Hct >65%
2. IDM, twin-twin transfuse, delayed cord clamp
3. also hyperviscosity of blood
4. seizures, PPHN, CVA, ischemia
5. partial exchange transfusion

Newborns have a 2-3x greater production of bilirubin due to ___ and ___

increased RBC mass and shorter RBC lifespan

breastfed infants d/t decreased fluid intake (breast feeding jaundice) and inhibitors to conjugation and promoters of resorption (breast milk jaundice)

kernicterus

Mid stage: High-pitched cry, Bulging fontanel, Seizures

Late stage: hearing loss, Mental retardation, Muscle rigidity, Speech difficulties, Seizures, Movement disorder

light at 420-500 nm converts bilirubin to a water-soluble isomer (lumirubin) that is readily excreted

exposure to high oxygen conc - retinal vessels constrict - vaso-obliteration - neovascularization - retinal detachment

<32 weeks or <1500 grams

• Intraventricular hemorrhage is bleeding from the ____ into the ventricles in preterm infants, particularly following an episode of ____.

• May present with ___, ___, or ___ but often ___.

• Diagnosed via ___

• May progress to ___

• germinal matrix; asphyxia
• bulging fontanelle, apnea, or seizures but often asymptomatic
• ultrasound
• post-hemorrhagic hydrocephalus

Classification of IVH

Grade I:

Grade II:

Grade III:

Grade IV:

I: germinal matrix

II: IVH w/o ventricular dilation

III: IVH with ventricular dilation

IV: IVH with parenchymal involvement

- acquired d/o of bowel ischemia/necrosis with secondary bacterial invasion found primarily in premature infants

- seems to be related to degree of ___, degree of ___, and ___

Necrotizing enterocolitis

degree of prematurity, degree of gut perfusion, feeding status

feeding intolerance, abd erythema/distension, bloody stool, signs of shock, bilious emesis

What does abd x-ray of NE show?

CBC?

sentinel loops, pneumatosis intestinalis, portal vein gas, free air

leukocytosis or leukopenia and thrombocytopenia

broad spectrum abx, bowel rest, transfusions, blood pressure support, close watch.

premature infants, PROM, and chorioamnionitis

1. Group B Strep
2. enteric GNR (E. coli)
3. Listeria

neonatal period

Toxoplasmosis

Other

Rubella

Cytomegalovirus

Herpes simplex

TORCH

- notable for eye findings (chorioretinitis) and intracerebral calcifications

- IUGR, +/- hydrocephalus

Toxoplasmosis

TORCH

- notable for IUGR, hearing loss, eye findings (cataracts, uveitis), blueberry muffin rash

Rubella

TORCH

- hepatosplenomegaly, chorioretinitis, intracerebral calcifications, LBW

CMV

TORCH

- seizures/encephalitis, skin rash, chorioretinitis

herpes simplex

- NOT prevented by topical prophylaxis

- usu presents after 1st wk of life w/eye d/c

How do you diagnose chlamydia conjunctivitis?

Giemsa staining and DFA of scraping

1-2 wks of rhinorrhea followed by staccato-like cough w/o wheezing, most cases afebrile

Chlamydia pneumonia

Dx: nasopharyngeal cx, CXR, IgM >1:32

Tx: Erythromycin

- IS prevented with prophylaxis (usu erythromycin)

- d/c at 2-5 days of life, bilateral and purulent

- may lead to corneal perforation and blindness

Ophthalmia neonatorum

Ceftriaxone

triple dye to umbilical cord

CF, sickle cell

How do you treat toxoplasmosis?

• Pyrimethamine
• Sulfa drugs + folate

CMV

Acyclovir

Varicella-Zoster

Those whose mothers acquire varicella just before or just after delivery

• interstitial keratitis, VIII cranial n. deficit, Hutchinson teeth
• associated with congenital syphilis

How do you treat congenital syphilis?

Penicillin