neonatology - dr abo-elasrar - by el azhar medical students 2012

8/13/2019 Neonatology - Dr Abo-ElAsrar - By El Azhar Medical Students 2012

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( BETA EDITION)

With

Prof. Dr Mohammed Abo El-Asrar

Edited By

El-Azhar Medical students 2012


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2 61eonates60...62 ..

ystem Respiratory disease of the newborn

of respiratory distress in the new born)Respiratory centre

tachypnea slow and irregularrespirationb)Frequent apnea

c)May central cyanosis. still immature R.C. :

Pre termSo, R.C....ay still immatureexposed to severe hypoxia

severe hypoxia,R.C.Ante natalbrainsevere hypoxia

post natal or natal

malformations in resp. center :

Malformation in respiratory centrenarcotic

narcoticplacentaR.C.IC Hge

intra cranial hemorrhagemeatabolic

etabolic disorderHypoglycemia

Hypothermia May hypocalcemia, hypomagnesemia

espiratory distressew bornentral causes of respiratory distressN.B.

Transient or permanent???? transient or permanent


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Peripheral causes of respiratory distress .eripheral

chest...signs of distressTachy pnea

Working ala nasi

Accessory muscle Grunting

-new bornhin tugaccessory musclerespirationnew bornTerminal case only

Contraction in lateral labialis muserious hypoxiarespiratory centrefrequentattack of apnea

- aspingeripheral

PulmonaryExtra pulmonary

LungAlveoli

surfactant()alveoliinflationhyaline membrane disease

alveoliinflationOne lobe or morery collapsery atelectasisMild respiratoryrespiratory distressinfectionalveolipneumonia

distressalveoli10 %gas exchangeextra-alveolar as :

aspiration...lungairwaymniotic fluid -meconium

extra alveolartension pneumo thoraxIatrogenicampo bag respirationamponew bornapproximation of fingers..tension pneumo thorax[]

congenital emphysema :

-congenital emphysema ung


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Bilateral post choanal atresia.surgery ..nose

oro-pharynx-

May be laryngomalacia or laryngotracheomalacia.-trachealarynx..cartilagecollapsing

May vocal cord paralysis.May laryngeal web..Tracheo-esophageal fistula

aspirationairway...esophagus...trachea-.

Gastro-esophageal reflux.Diaphragmatic hernia or paralysis.

NT yaline membrane diseaseHyal ine membrane disease

= Respiratory distress syndrome type one

respiratory distress syndromeType one & type two

ype onehyaline membrane diseaseidiopathic respiratory distress syndromeype twoTransient tachy pnea of the newborn

Type one alveoli...Type two alveolar cell]type onemucous[ype two alveolar curfactantsecretionsalveolidry...

Inspiration

urfactanlecithinPhospholipidsphingomyelin..lecsupra renalcortisone

supra rencortisone35 weeks gestational age37surfactant

:Risk factors

-surfactantrespiratory distress type onePre term

-37surfactantpretermhyaline30surfactant

36


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Infant of diabetic mother May be preterm

Hyperglycemia fetushyperglycemiapancreas(fetus)(water

solubleplacenta)antagonist effect on cortisone

So, no ability of conversion sphingomyline to lecithinAnte natal or natal hypoxia

supra renal hemorrhagecortisonesurfactantCesarean section

36surfactant(vaginal)erine contractionsurfactantLevel3cortisonestress

Pre termstress

)

Pathophysiology

yaline membrane diseaseintra uterinealveolicollapsedMucoustype one

35cortisonesurfactantalveolidry..2layersInflationalveolisurfactantalveolimucous secretionalveolisecretionsinflationsurfactantInflation

nflation 2-PO2CO2

So, CO2 respiratory acidosis

PH...Hypoxiaanaerobic metabolismorganic acidMetabolic acidosis

respiratorymixedrespiratory and metabolic acidosis-ypoxia.D.lood vesselsulmonary artery.C.


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lung...alveolihypoxiahyper capniadosis....More vaso constriction.....Viscous circlepulmonaryV.D.

hypoxlimitigns of peripheral respiratory distresslow and irregular respirationR.C.hypoxia-

frequent attacks of apneaDiagnosis

linicallyHistory of one of the risk factors35DMPlacental infarctionhypoxiacesarean section

36-35signs

( no complaintcyanosis or not)

Auscultation:

auscultationair entry is markedly diminished

bronchial breathing as most alveoli fine crepitation

in elastic alveoliall over the chestuscultationmergency espiratory depression ..Etc.

Investigations-Peripheral signs of distresshyaline membrane disease

tracheal secretionsaline()bubblessurfactant((

-bubblesX-ray

hyaline membrane diseaseradeGrade 4

alveolirade fourlungGrade 3

airwayrade threeGrade 2

Lungalveoliinflatedground glass appearancerade twoGrade 1

bronchopneumoniarade oneBlood gasesPO2CO2PH


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iagnosisManagement

Preventive avoidance of the cause.Avoidance of causes of prematurity. Diabetic mother .

-good management of DMAvoid ante natal and natal hypoxia

screeningAvoid cesarean

itembadly time cesarean section...ung mature...r still immature(DM

a)estational ageb)mniotic fluidecithinphingomyelin

L/S ratio-2surfactant

-2surfactant dexamethasone..placenta

fat solublewater solublematurationLunghyaline membrane disease

- ICU

neonatal ICUsource of infection New bornheat regulating centre ...Hypo thermia37

40 %humidityairwaydrynessairway

O2 therapy non distressedIV fluids2/3distressed

hypoxiaADHhyper volemia-distressedoral feeding

Proper antibiotic therapy Infected


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give surfactant :

surfactantsurfactant/S2...surfactant...

endotracheal tubettt of hypoxia , hypercapnia , acidosis

surfactantInflationalveolihypoxia & hyper capniab2 therapyechanical ventilatorechanical ventilator

PH7.2...PO250....CO260apnea

=espiratory failurePO26080O2 toxicity()

Retinopathy

Broncho-pulmonary dysplasia

cidosisNa bicarbacidosismechanical ventilator-

Good care of baby in ICU :

good care of baby in ICUnutritionOralVit. K

entilatorO20 exchange transfusionHb FHb F

Hb AO2Complications of NIUC

NeonatologyPrognosis

rognosis of hyaline membrane diseaseacilities of ICUInfection control of ICU Experience of personnel

150%50 %2-595%5 %

Respiratory distress type two

Called transient tachy pnea of the new bornachypnea

persistent of lung secretions


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pretermfull termsurfactantairwaysecretionsynormal vaginal delivUterusvaginasqueezinglungsecretion

cesarean sections-signs of distress-secretions

coarse crepitation & sonorous rhonchimask of O2 Meconium aspiration syndrome

-Meconiumfeces...etusefecationntrauterine lifeefecationntrauterine

hypoxiarelaxation of anal sphincterIntrauterine lifemniotic fluidamniotic fluidmeconiummeconiumMouthnose

secretionnaso & oro pharynxmeconiumirwaycomplete obstructionpartial obstruction istressed......ventilatoralveolipartial obstruction

pneumo thoraxalveolicomplete obstructionMeconiumabsorption collapse Neonatology ....

meconiumMeconiumvaginaamniotic fluid

-

-cephalicbirth canaltruck

trunktrunk..spontaneous respiration-supportperineum

nosenaso-pharynxmeconium -breech

vaginarespirationtrunk

aspirationMeconium-23


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Neonatal apnea

central respiratory depressioncentral respiratory depression Causes

May mother take narcoticsaddicts

May RC still immature PTmalformation of RCintra cranial hemorrhagecompressionRCpontine hemorrhage

May sepsis-meningitisencephalitis

Any peripheral cause of respiratory distress-severe hypoxia

Metabolic causesallN.B.

NEC = necrotizing enterocolitis = severe sepsis cause necrosis in gut .sepsisManagement

esuscitation

Hypoglycemia in the new born

... ypoglycemia

3glucose level35 mg /dlhypoglycemic level 324glucose level40 mg /dl1 dayglucose level45 mg /dl

hypoglycemiaCauses

glycogen stores in liver.1.2 hyperinsulinemiaendocrine

hypoglycemiacounter regulatory hormonesblood glucose3. counter regulatory hormones

.4 Excess requirementsIn born error of metabolism.5

glycogen stores as in PT & IGR

9Preterm....


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3organogenesis3Preterm....stores337full term2.5-3.52.5called intrauterine growth retardation

nutrition lycogen storesExcess insulin

RH _ncompatibility

RH incompatibility...As anti D cause stimulation of islets cells of pancreasso, more insulin

hypo calcemia&Hypomagenesemia , hypo glycemiaInfant of diabetic mother

Infant of diabetic mother


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So, one of causes of hypoglycemia RDS congenital cyanotic heart disease , HF, .etc-glycogen storage disease.....glucosegalactosemianfant of diabetic motherIn general

Infant of diabetic mother-DMHyperglycemia

-oral hypoglycemictype twomost commonOral hypoglycemic is absolutely contraindicated during pregnancy

-insulin phobiahypoglycemia-hyperglycemia

Maternal hyperglycemia during pregnancyPathophysiology

glucosemono saccharideMonoplacentafetal hyperglycemia....

multiple congenital anomalies

-3Period of organogenesis-glucoseteratogenic effect...Cause multiple congenital anomalies in baby

As congenital heart disease ..Etc.

hyperinsulinemia

Fetal hyperglycemia Cause fetal hyper insulinemia insulin is an anabolic hormone

anabolic hormoneglycogen synthesis, lipid synthesis & protein synthesis

4Macrosomiabrainphospholipid 1- PT

...4(4)35stretchuteruspremature uterine contractionpremature delivery..So, preterm

2- Birth injuries

full termvaginalbirth injurybirth canal Insulin has antagonistic effect on cortisone RDS I

Has antagonistic effect on cortisone so, no conversion of sphingomyeline to lecithin 35..RDS type one


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Insulin stimulation of erythropioesis Polycythemia Stimulation to erythropioesis intrauterine that occur in spleen and liver

...RBCs count...Plethoric faceBCs

a- Thrombosis

blood viscositythrombosisb- Jaundice even Kernicterus

-RBCsindirect bilirubinjaundice-Indirect bilirubinsaturation levelMay kernicterus

After delivery Hypoglycemia hypoglycemia

-hypoglycemiaTrue convulsion+Due to peripheral vasoconstriction((epinephrine

-central depressionPoor reflexespoor suckling-of R.C.Cyanosis

athophysiologyClinically

Large More than 4 Kg.

Plethoric features.

Manifestations of hypoglycemia. nfant of diabetic mother

Complications

Multiple congenital anomalies, congenital heart disease. pelvic and lower limb anomalies

Due to embryonic hyperglycemia.

Macrosomia birth injuries & prematurity.

RDS type one.

Polycythemia thrombosis.

Neonatal jaundice & kernicterus.

post natal hypoglycemia Management of infant of diabetic mother & hypoglycemia hypoglycemiarisk factors

As DM mother , preterm, IGR , RH incompatibility

-hypoglycemic level or notypoglycemicne of risk factors


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:tart oral feeding as early as possible

frequent breast feeding to oral intake of milk or glucose-24

()..()(

.. (IV lineglucose(Hypoglycemia()24IV glucose24

-IV glucoseglucosecortisoneAs counter regulatory hormone

specific antidotehypoglycemiaglucagon life saving drug in hypoglycemia as it is a

-hypoglycemiahyperinsulinemiaCa gluconate , Mg sulphate1

.F.nfant of diabetic motherCongenital heart diseasePolycythemia

hypervolemiacongestive heart failure

yper insulinemialucose ypoglycemiaypoglycemia

...9in secretion Revision of hematology in new born

Bleeding in the new born

hematologyNewbornCauses leeding

vascular causevesselsNo vasoconstriction plateletscoagulation factors....Coagulation factors defect

Intrinsic

12, 11, 9 and 8Extrinsic


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7,Common pathway

10, 2 and 1factorsPathway...newborn

1-Vascular cause

pretermfatvessels So, fragile capillaries in preterm

2-Platelets defect

May defect in function thromboasthenia.

hereditaryVon-Willbrand factor deficiency

plateletswallvesselsglycoprotein 1 breceptorsBurnard soluir disease

May glycoprotein 1balled Burnard soluir diseaseGlanzman's disease ADPdeficientglycoprotein 2B, 3AplateletsGlanzman's disease

Aspirin

Teratogenic effectPlacentaof COXSo, no ADPNo platelets aggregation

May defect in platelets number thrombocytopenia.

a- decrease in synthesis

synthesis...bone marrowSTORCH infectiondepression to bone marrowsepsis-

- Or TAR syndrome

-hrombocytopenia with absent radiusTARstem cellsThrombopiotein receptors+autosomal recessive genesent

radius

b- Excessive destruction

1- Antibosies -antibodiesidiopathic thrombocytopenic purpura

antibodyIg Gplacentatransient Idiopathic thrombocytopenic purpuraSLE

2- Isi immune thrombocytopenia

-PlateletsantigenpositivenegativeRH


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-negativepositiveantibodies3-Coagulation factor defects

emophiliaType A-X-linked recessive geneType B-X-linked recessive geneType C-1utosomal recessive gene

factorsintrinsic pathwayFactor one afibrinogenemia or dysfibrinogemia. Congenital factor 7 deficiency extrinsic pathway defect.

vitamin K 1972

emorrhagic disease of the newbornIf DIC consumption of coagulation factors + platelets thrombocytopenia.

Hemorrhagic disease of the newborn

coagulation factorsircumcision....

causes Vitamin K

Maternal deficiency of Vitamin K.So, stores of vitamin K in baby

Vitamin K need bacterial flora.-vitamin KLiver

Still immaturebacterial flora-May liver is still immature.

Diagnosis ( C/P + Investigation )-

Epistaxis, at site of IM, passing of blood in stool, at site of umblical cord

ntracranial hemorrhage2, 7, 9 and 10PTprolonged...11, 10, 2intrinsic

common...So, prolonged PTTPrevention

-..4- 610 mgK..Intra muscularvitamin K 1mg Intra muscular-

2-5


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-vitamin K3

-fresh frozen plasma or fresh bloodvitamin KAnemia of the newborn

A - Physiological anemia-

placentaO2LungPartial tissue hypoxiaintrauterineHemoglobinHb F

Poor O2 dissociation

RBCs that contain Hb F

120...60intrauterineLiverspleenMore RBCsintrauterinePolycythemiaNormal

hemoglobin18-22 gram %

-Lung...O2erythropioteinRBCs synthesisHb

% 9 gramHbRBCs-45Hypoxiabone marrow

Physiological anemia is more severe in preterm whyvitamin E...Which is an antioxidant...RBCs

B - Pathological anemia

Causesnemia in general

ematologysynthesis

-requirements-requirementsbone marrow

sepsisorSTORCH infection

Excess loss hemolysis >>> Defect in RBCs itself :Cell membrane as spherocytosis.

Enzymatic deficiency G6PD.

May abnormal Hb alpha thalassemia.

Extra corpscular causes.


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Antibody RH or ABO incompatibility

Or autoimmune hemolytic anemia of mother Non immune as toxins as in sepsis .

May excess lossa- Placental Hge

placental hemorrhagePlacentaumblical cordb- Feto-fetal transfusion

)(placenta2- ..Called feto-fatal transfusionc- Feto-maternal transfusion

-separation of placenta-5 cm5 cm...10 cm()

Excess loss after delivery.Cephal hematoma.

Intra cranial hemorrhage.

Bleeding umblical stump.

Bleeding requent sampling)(-

atrogenic anemiaInvestigation

Synthesis or loss ??CBC + Retics >>>

retics & Hb >>> so, bone marrow defect.

retics & Hb >>> so, hemolysis Treatment

Treatment of underlying etiology + may packed RBCs transfusion .Cyanosis in the newborn ..

Causes

Slow and irregular respiration + frequent apnea

>>> Pulmonary or extra pulmonary.Signs of respiratory distress


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a- Transposition of great arteries

Aortaright ventriclePulmonaryLeft ventricleransposition of great arteries"TGA"

b- Single ventricle (no inter ventricular septum)

c- Tricuspid valve atresia

Tricuspid valve atresiaforamen ovaleleft sided- Pulmonary atresia

Pulmonary atresia...e- Fallot tetralogy very rare

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Fever in newbornthe neoantes

Dehydration fever.Neonatal infections.

Dehydration feverCauses of dehydration fever

3-sucklingInitiate breast secretion

-..........(... )sweating

water loss

Clinical picture

High temperature.


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if delayed breast milkLow grade fever38- 38.2

If excess sweatingHigh grade fever40

Signs of dehydration .GIT

- As highly irritable Due to dry mouth

40() - Sunken eyes, depressed anterior fontanell, dry mouth, dry inelastic skin, urine output

urine outputTypes of dehydration in newborn

newbornHypertonic dehydrationsweatingLoss of watersaltsdehydration

Treatment

Correction of dehydrationPrognosis

o bad Maternal disease affecting the newborn

as STORCH infection.-Organism

-placental insufficiencytermination of pregnancy-Preterm...Hypoxia intrauterine due to infarction in placenta

he mother.-IgGtransient(3)

As ITP, autoimmune hemolytic anemia, myasthenia gravis, auto immune thyrotoxicosis and SLE

Phenyl alanine restrictiondiet phenyl alanineAs mental affection

, stores as in

Vitamin D. IDA IDA < 6 months.


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Low birth weightIntroduction

Normal birth weight 3-3.5 plus or minus 0.5 kg.If > 4 kg large.

If < 2.5 kg low birth weight.

If < 1.5-1 kg called very low birth weight.

If < 1 kg but may reach 0.75 kg extremely low birth weight.If < 750 gram impossible low birth weight.

Causes

-2.5 kglow birth weight May preterm.

37gestational ageNB

pretermlow birth weight2.5 kgMay full term.

-3740NB

post date40-3-3.5 plus or minus 0.5 kg

If full term < 2.5 kgntrauterine growth retardation1 kg & 900 gram

a) Preterm 60 %.b) IGR 40%.

prematurityCauses of prematurity

50 % of prematurity idiopathic. 50 %

...... (432(-4 kg4)...3PrematurityUteruscapacity)2

distentionstretchUterine contractionDM during pregnancymacrosomoia large baby

4.5preterm


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or complication of DM during pregnancy

diabetes-Nephropathy , DKA etc

termination of pregnancyseveretermination of pregnancy(30)toxemia of

pregnancy

placenta priviaplacentaAnte partum hemorrhage Causes of IGR

Chromosomal abnormalities.As Multiple congenital anomalies

May STORCH infection .anomalies

May teratogen to mother anomalies.Any cause of placental insufficiency.

Clinicallyretermull term with IGR900:

DD between PT & IGR ( FT ) () 1- Assessment of gestational age

... From history

Date of last menstrual period ...accurate

Date of onset of fetal movement.(primi garvida)18-20

-(multi para)16- 18 primi gravida

Antenatal examination-fundus of the uterusFundal levelage

-false impressiongestational age Ante natal investigations .

U/S ( sonar )


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bi parietal diameter of the skullbi acromion diameterNB.

3737 Amnio-centesis.For lung maturity L/S ratio

For kidney creatinine.

2- At birth. A - Physical signs

Head a- Hair

- :...pretermFull term-

b- Earcartilage of earformedfull term-

formedpretermNipple of the baby

diameter If > 3 mm (0.3 cm ) full term

If = 3mm (0.3 cm ) or less PretermGenitalia

If female-labia majora cover minorafull termmajora not cover minorapre term-

If male-testisscrotumfull term

-undescentfew ruguepre termLegs

-soleno creases()one2preterm(full term)crease cross pattern2-

B - Neonatal reflexes neurological evaluation retermcriteria

Handicaps & complications of prematurity


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(eonatology(a) RC still immature central respiratory distress and apnea.b) RDS type two.) Weak respiratory muscle.

-shallow respiration-weak ciliasecretionsecretionstagnant

repeated chest infectionsd) Blood vessels.

fragilePulmonary capillarieshemoptysis.

If any respiratory problem tissue hypoxia blood that pass through PDA contain PO2 >>

layed closure of PDA

. :DAendotheliumO2 sensors PO2endotheliumPGE2

relaxation of the smooth ms around DA still patent

intrauterineb) Hypoxia cause VD of all except pulmonary artery VC pulmonary hypertension.

heat regulatory centrebrainIf temp heat loss + production .

1-generalized hypotonia & muscle weakness muscle contractionheat production

-peripheral vesselsVDflushing-sweating

dehydration fever

....heat regulatory centreheat production By shiveringMuscleS.C. fatheat loss

heat losssurface area1.70.5

So, more heat loss

Contain stores as CHO, iron , vitamin D , vitamin K .stores

So, decrease in all stores :


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CHO hypoglycemia. Iron iron deficiency anemia before 6 months . Vit. D rickets before 6 months. Vit. K hemorrhagic disease of the newborn.Also, liver secrete coagulation factors so, here liver is still immature .

- So, PT & PTT ( all factors )

Also, bile salts .

digestionfatfat(( Steatorrhea olestrum...ess fat contentAlso, enzymes still immature

s glcouronyl transferase enzyme. + Z & Y protein still immature So, physiological jaundice. 14))

.

a) Muscles of mastications are weak.So, weak suckling.

b) Also, muscle of the pharynx .weak swallowing) Small capacity of stomach.d) Malnutrition & mal absorption as bile salts & digestive enzymes.e) GIT motility problems as exaggerated gastro-colic reflex

-()-motilitycolonsuckling

- Or gastro-esophgeal reflux GITITypoglycemia

.

Still Immature GFR. , glomerular & tubular functionSo, failure of the kidney to concentrate urine.

Why ??? coagulation factors , vitamin K ( liver still immature ) . Fragile blood vessel .

immunity passive immunity

3IgG3 Also, active immunity .

epsis(Liable to any infectionmmatureomplications

Hypothermia of the preterm.Hypoglycemia in preterm.


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Why Hypoglycemia in PT ???1) Stores (CHO).2)Hyper insulinemia if infant of diabetic mother.3)Counter regulatory hormones.4)consumption as

infection and hypoxia5)Intake.6)Absorption.

NB. IGR compliacations as PTManagement of low birth weight

Prevention preventable.- Avoidance of causes

N.B. Normal glucose level in newborn as in adult. ...

Avoid badly time Cesarean sectionCesarean sectionllCurative .

Neonatal ICU.

.. infection

O240 60%

Feeding .

Oral feeding....Onset :

as soon as possiblehypoglycemiaMethod

a- capable of suckling & swallowing:

-sucklingswallowbreast or bottle breast (


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ottleb- If only swallowing

breast milkformulac- if no ablility to swallow

Naso gastric tube

- Type of feeding

1- Breast milk......-

2- Artificial milk. PT formula

-Preterm formulafull termCysteine + taurine-Methionine to cysteine & taurine

brain growth -

pretermcysteine and taurine(3- If preterm formula not available.

-4560Give full term formula... -naso gastric tubeIV fluid,,,,

As in intracranial hemorrhage respiratory distress- Amount of milk

5cm.... V fluids requirements

Full termstart at 1st day of life60 ml / kg

Preterm80 ml / kg

150 ml /kg / daymaximum10- 20 ml /kgimmunityfully steralized(

)Give broad spectrum antibiotics Penicillin + gentamycin

May immunoglubin needed

Vitamin K. Vitamin E. Vitamin D & iron.

-()stores45

Birth injuries


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Head injuries

1. Caput succedaneum-edemapresenting part of the scalpscalp

alled cephalic presentationskullCesarean section)birth canal(

Obstruct venous drainage edemascalp-edemabirth canal ephal hematoma

Sub-periosteal hemorrhage

Normal at birth caput succedaneumMaximum at birth

As it is a sub-periosteal hemorrhage Doesnt cross suture lines

caput succedaneumcross suture linesscalp- due to obstructive labor

-courseregressive courseJust reassurance of parents 2. Cephal hematoma Also, cephalic delivery. Obstructive labor.

-Forcepssub-periosteal hemorrhageskullintra cranial hemorrhage-

-welling imitot cross suture lineComplications

As it is ablood loss so, may manifestations of anemia as severe pallor.

Hemolysis of its RBCs indirect billirubin.

May 2ry infection.

Iatrogenic-drainagehematomapressureblood vessels

drainage-drainageorganism

Infected hematoma

healing by fibrosis & pathological calcification .Disfigurment of skull

Investigations

Brain U/S.Intra cranial hemorrhage

Also, CT & skull X- ray.skull

Treatment


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If anemia packed RBCs.

If billirubin phototherapy, even exchange transfusion.

Antibiotics to treat 2ry bacterial infection.

bacteremia2ry infection fibrosis & calcification

blood clotfibrinolytic system(..)

resorption & resolution3. Intra cranial hemorrhage

CausesBirth injuries.

Hypoxia vaso dilation of cerebral vessels So,incidience of intra cranial hemorrhage

Vascular anomalies as congenital aneurysm of cerebral vessels.

May hemorrhagic disease of the newborn.

Bleeding tendency. Prematurity.

Fragile blood vessels. Liver immature coagulation factors. Vitamin K stores.

Clinical manifestationsntra cranial hemorrhage

Anemia pallor High pitched cry Tense and bulging anterior fontanell

3You must exclude intracranial hemorrhage

intracranial tensionTriad Intra cranial tension Only high pitched cry Projectile vomiting ) not proceded by nausea) Bulge & tense _ontanel


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may poor feeding

centresLoss of neonatal reflexes

Drowsy even _onvulsion & deep coma

Eye unequal pupil

Investigations

Brain sonar. CT & MRI.

Treatment

Incubator a) Position raise head 30 degrees

bleedingheadb) Feeding. If convulsion give IV fluids. If comatosed or drowsy tube feeding.

Give packed RBCs. Vitamin K. Fresh frozen plasma. Or fresh blood with no packed RBCs.

Convulsion give phenobarbitone-Neuro surgery

Peripheral nerve injury1. Erb's paralysis.

deliveryshoulder(klumpke's)shoubirth canalaxillabrachial plexus injury

C5, 6 roots,,Deltoid & biceps muscleabductionshoulder

Till 15 supra spinatus

15-90deltoid

More than 90upper fibers of trapizius

biceactionFlexion of elbow + supinationbrachio radiaC5, C6 and C7actionSupination + extension at wrist joint


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-eltoid + biceps ibersrachio radialisctionAdduction + internal rotation of the shoulder

(deltoid)elbow extension

(biceps)Wrist pronation + extension

(brachio radialis)Called policeman's tip position Here nerve

Motor affection Sensory affection Outer aspect of arm Loss of biceps reflex

Treatment

functioning muscleUnder stretch muscle spindle,,, muscle tone

(keep ms contracted)

So Shoulder external rotation + abduction Elbow flexion Wrist supination + extension

physiotherapy2. Klumpke's paralysis

Injury to C7, 8 and T1supplysmall muscles of the hand

Dropped hand Lost grasp reflex May Horner syndrome

sympathetic chainTreatemnt

hysiotherapy3. Diaphragmatic paralysis

May injuries to roots of phrenic nerve C3, 4 & 5paralysis of the diaphragm,,,,o, mainly thoracic respiration

If bilateral severe respiratory distressInvestigations


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iaphragm....y fluroscopyTreatment

Only supportive + surgical4. Sterno mastoid injury

Maceration and hematoma inside it later , fibrosis and calcification.-swellingtumorlymph node-6Torticollishard masstumor

TreatmentSurgical removal of sternomastoid Visceral injuries

pleenelivery of trunkResuscitation of newborn

PGAR scoreApgar score

(

Apgar irginia Apgar19091974

Medical eponym35)

Apgar scoassessment012full mark10......2..ull

mark10)(Naso pharynx)Apgar score(5)assessment

" 1- Color

Completely pink 2 marks.

Body pink & extermities blue 1 mark.

Blue or pale 0.

2- Movement

Active movement 2 marks.

Generalized flexion 1 mark.


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Floopy 0.

3- Reflex to nasal catheter

Cough & sneeze 2 marks.

Grimace response 1 mark.

Absent any reaction 0.

NBrimace 4- Respiration

Good crying 2 marks.Slow and irregular 1 mark.

Apnic 0.

5- Heart rate

More than 100 2 marks.

Less than 100 1 mark.

Arrested = less than 60 in newborn 0.

-apgarIf 8 - 10 good general condition & no asphyxia.

If less than 8 [7, 6 or 5] mild asphyxia.

If 4 or 3 moderate asphyxia.

If less than 3 severe asphyxia.

esuscitation ) ....O2) .Na HCO3 , Ca gluconate , glucose 10 %(2).naso & oropharynxApgar

(post choanal atresia(esophgeal at

pass meconium or notanus -pgar7

tactile stimulation of respirationsole(),,,(Pinching) - O2

-naloxoneumblical catheteropium-Just approximation of fingers

-Laryngoscope & do endotracheal tube ardic massageampo

-umblical catheter:() Glucose 10 % 2 - 4 cm


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Na HCO3 may acidosis Epinephrin heart

-heart rate100Ca gluconate((brady cardiahypocalcemia

Neonatal reflexes1- Moro reflex

1530phases Extension & abduction Then Flexion & adduction

Apperance28 weeks gestational age.Disapperance3-4 months.Significance:

If bilaterally absentmay so, central problems preterm, meningitis, hypoglycemia, hypothermany central cause.

If unilaterallocal cause Erb's palsy, fracture clavicle, dislocated shoulder. Still present after more than 4 monthsCP.

2- Grasp reflex Your thumb in palm,,,lso, in sole of footpalm 3- Rooting & suckling reflex

Rootingstimulation of the cheek around mouth and respond by turnning of the face & mouthwards stimulus.

Suckling-hard palate

-74- Stepping reflex

-5- Placing reflex

-dorsumfootunder surface...-15

6- Glabellar reflex

7- Tonic neck reflex

-supinerapid rotation of neck to one side


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Extension of limbsFlexion-7

8- Neck righting reflex

Slow rotation of neck to one side trunk follow the neck .

9- Parachute reflex Appear at 9 months & persist.

-pronextension of trunk & all limbs10- Landau reflex rone position

Extension neck and trunkflexionheadeneralized flexion11- Positive Babiniski sign

56Hypoxic ischemic encephalpathy

hypoxia... Intrauterine Fetal hypoxia

Etiology

ypoxiaO2..heartLungO2blood

blood vewall of uterusplacentaumblical cordfetus A - Fetal hypoxia

Maternal hypoventilation During general anasthesia. Heart failure. Or carbon monoxide poisoning.

Maternal hypotension blood to uterus Spinal anasthesia. Dehydration

Compression of aorta or IVC.

uterusblood to uterus upine

Uterine causesAs in uterine tetany


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-oxytocin()Oxytocinuterine contractionompress uterine vessels-

Placental causes Premature separation. Any cause of placental insufficiency.

Compression of umblical cord B - Extra uterine

All causes of cyanosis in the newborn...Central respiratory distress.Or peripheral respiratory distress.

Pulmonary. Extra pulmonary.

Clinical picturesIf intra uterine hypoxia.

1. IGR 2. Slow & irregular fetal heart rate

--:

3. Meconium stained amniotic fluidhypoxia........Relaxed anal sphincter

:vagina)(amniotic fliudProbescalpbaby()monitorPH... 4

4. Severe acidosis indicate hypoxia.-aspiration of meconium

-Hypoxia:5. Apnea & slow irregular respiration.

Heart rate or arrest, cyanosed, floppy

-apgarresuscitation6:()

6. Encephalopathy. 7. If more than 24 hrs severe brain edema and may death.8. Convulsions

euronal cells


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9. Then disturbed level of consciousness even deep coma.Management

1-:Avoid causes of fetal hypoxia As,

spinal anesthesia 2-:

a) Prevent meconium aspiration b) Resuscitation) If convulsion anti convulsion

Investigations Prognosis

No brain damage with CP death

Necrotizing enterocolitis ( NEC )hypoxiagut ischemia

necrosismucosagutgut ulcerinfectionnecrosis Ischemic necrosis. Toxic necrosis.

Clinically

Paralytic ileus Hypoxia or ischemia. Toxiemia toxic ileus.

-newbornbileAlso, abdominal distention & constipation (no colic ) .

Ulcers bleed :hematemesis

melena or bleeding per rectumAlso, may perforation occur

Due to ischemia & infection >>> Peritonitis tenderness


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Hypoxia slow irregular respiration even apnea.Heart rate is irregular

Toxaemia- May hypothermia, hypoglycemia , hypocalcemia, hypomagnesemia .

-clinicallyinvestigationsinvestigations

NECtriad(Investigations)Thrombocytopenia Sepsis bone marrow Or destruction of platelets

Persistent acidosis hypoxiaorganic acid

Persistent hyponatremia- As sepsis erosion of gut >> No absorption of Na

- Also , May due to supra renal hemorrhage. >>> Addison1 , 2 & 3May blood in stoolX- ray air under diaphragm

Treatment No oral feeding, only IV fluids. Naso gastric tube & suctioning. Treatmetn of any complication as :

antibiotic according to culture and senstivity.Penicillin & gentamycin

2- Bleeding platlet or FFP or fresh blood.

3- correct acidosis & hyponatremia.

4- If air under diaphragm which indicate perforation so, surgery is needed

NB.

NEC & Hypoxic ischemic encephalopathy high mortality rateneonatology3:1- Meconium aspiration.

2- NEC

3- HIE


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eonatology5nfections eonates61&60

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neonatology - dr abo-elasrar - by el azhar medical students 2012

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