Apgar Scores - Definition

When conducted?

Predictive of long-term neuro outcome?

Apgar score in those with CP?

What scores plus labs are indicative of increased mortality?

Appearance          pale/blue        peripheral cyanosis            pink

Pulse                      none               <100                                    >100

Grimace                none                grimace                                cry

Activity flaccid some flexion active

Respiration none slow, irregular good cry

Apgars done at 1 and 5 minutes, and every 5 minutes therafter as long as resuscitation continues

Apgars do not predict long-term neuro outcome, but <3 beyond 10 minutes is predictive of worse outcome, scores >7 considered good

Scores are normal in those with CP

5 minute score of 0-3 plus umbilical artery pH of <7.0 significantly increases risk of neonatal mortality

Initial steps of neonatal resuscitation

if thick, particulate meconium, do what?

Place under a radiant warmer (prone to heat loss due to high surface area:body mass ratio; if cold stressed, will rapidly deplete stores of glycogen and fat

Suction trachea (if thick, particulate meconium is present in a non-vigorous infant --> intubate, visualize cords, suction thru ETT

Dry

Position head --> suction mouth, then nose

If decreased responsiveness --> tactile stim

THEN EVALUATE respirations, heart rate, color

presence of meconium

decreased breathing or crying effort

the infant is not pink

there is decreased tone

gestational age is less than term

Initiate chest compressions at 120/minute

compression:ventilation ratio of 3:1

compress lower third of sternum:

with two fingers perpendicular to sternum, or

with thumbs, with fingers encircling chest

BIRTH TRAUMA - Caput Succedaneum

key diagnostic words

first diagnostic step in management

treatment

prognosis

Presenting scalp (most often parietal or occipital)

fluctuant edema (most often serous)

above periosteum

crosses suture lines

no diagnostic steps

if hemorrhagic (less common) and patient is jaundiced, follow bili

resolves completely within days

BIRTH TRAUMA - cephalohematoma

key diagnostic words

first diagnostic step in management

treatment

prognosis

Subperiosteal blood

usually hard mass

does not cross suture line

possible underlying linear skull fracture

most important is to follow bili; skull radiographs only if severe cephalohematoma and concern for significant fracture

may need phototherapy

most resolve in 2 weeks to 3 months; may have calcium deposition for up to 1-5 years

BIRTH TRAUMA - Subcutaneous fat necrosis

key diagnostic words

first diagnostic step in management

treatment

prognosis

difficult deliveries and with maternal cocaine use

at sites of trauma --> well defined, hard irregular lesions of skin

necrosis at 6-10 DOL

none unless anorexia, vomiting, irritability, and increased sleep --> obtain serum Ca

may need to treat significant hypercalcemia w/IVF, furosemide and hydrocortisone

becomes soft within 2 months, then regresses

BIRTH TRAUMA - Skull fracture

key diagnostic words

first diagnostic step in management

treatment

prognosis

most often linear and with cephalohematoma

usually not recognized

depressed - mostly secondary to forceps delivery

palpable indentations

none unless depressed --> x-ray, possibly CT if suspect underlying birth trauma

usually none, unless large and depressed --> immediate surgery

most heal within months wo/problems

BIRTH TRAUMA - facial nerve paralysis

key diagnostic words

first diagnostic step in management

treatment

prognosis

most often with forceps delivery

1st or 2nd day after birth --> smooth forehead, open eye, no nasolabial fold, corner of mouth drops on ipsilateral side

tongue not affected so feeding is fine

none

none

most resolve within days-weeks

months in most severe (uncommon)

BIRTH TRAUMA - subconjunctival hemorrhage

key diagnostic words

first diagnostic step in management

treatment

prognosis

red patch in bulbar conjunctiva

common with any delivery

none

none

absorbed in 1-2 weeks

BIRTH TRAUMA - clavicular fracture

key diagnostic words

first diagnostic step in management

treatment

prognosis

Most frequent neonatal fracture

difficult delivery of shoulder in vertex or extended arms in breech

may not be seen until callus formation at 7-10 days

if complete --> presents at birth with irritability (pain), decreased arm movement, discoloration, deformation at clavicle, no Moro on ipsilateral side

plain radiograph

control pain --> immobilize arm/shoulder

bone contour normal after several months

BIRTH TRAUMA - brachial palsy

key diagnostic words

first diagnostic step in management

treatment

prognosis

Duchenne-Erb - more common; prolonged and difficult delivery

C5-C6, upper arm involved

arm adducted and internally rotated w/extension at elbow

pronation of forearm

no reflexes

Klumpke - rare, C8-T1 (Horner syndrome)

hand and wrist paralyzed

plain radiographs of shoulder including lower cervical spine, clavicle and upper humerus to exclude other bone/soft tissue injury

PT and monthly evals

if no correction by 3-9 months --> explore brachial plexus for surgery

most resolve completely

others may have improvement w/early surgery

BIRTH TRAUMA - Phrenic nerve injury

key diagnostic words

first diagnostic step in management

treatment

prognosis

Most unilateral w/ipsilateral brachial palsy

hemidiaphragmatic paralysis

lateral hyperextension w/stretching of C3-C5

recurrent cyanosis, difficult respirations w/no diaphragmatic movement

decreased breath sounds

plain radiograph --> elevated diaphragm, shift of mediastinum to opposite side and atelectasis bilaterally

best test; real time US

position w/involved side down, O2 as needed, IVF

may need ventilation

if no resolution within 2 months --> surgical plication of diaphragm

most recover spontaneously

BIRTH TRAUMA - sternocleidomastoid injury

key diagnostic words

first diagnostic step in management

treatment

prognosis

muscular torticollis

hyperextension in difficult breech or head delivery or in-utero constraint

hematoma --> scarring --> muscle shortening

may see at birth or 10-14 days after birth

head forward to involved side and chin to opposite shoulder

plain radiographic studies to exclude other pathology

daily stretching exercises, stimulate infant to look in involved direction

place on affected side during sleep

try for 6 months, if no improvement --> surgery

most recover within 2-3 months

if not corrected by 3-4 years, skull becomes foreshortened and may have lower cervical and upper thoracic scoliosis

remove blood/meconium from body w/warm water or non-medicated soap after temp has stabilized.  Dry and warm in sterile blankets.  Clean perianal area and buttocks w/water or mild soap w/diaper changes

umbilical cord - one-time application of triple dye followed by 2x/d of alcohol swab until the cord falls off; or daily bacitracin to the cord

single intramuscular dose of 0.5-1.0 mg of natural vitamin K1 oxide within 1 hour of birth to prevent hemorrhagic disease of the newborn

instill either 1% silver nitrate (not adequate for chlamydial infection) or 0.5% erythromycin (or 1% tetracycline) to prophylax against ophthalmia neonatorum

routine recommendation of circumcision not evidence-based.  If done, give appropriate analgesia

Who are the high-risk infants?

What are the definitions of each?

Premature or preterm delivery - <37 weeks

Low birth weight - <2500g

very low birth weight - <1500g

intrauterine growth retardation

What is a significant cause of in-utero infection?

What is the most accurate predictor of neonatal mortality rate?

What are the side effects of IUGR?

in-utero infxn - chorioamnionitis

The most accurate predictor of neonatal mortality rate is very low birth weight

IUGR infants are more prone to fasting hypoglycemia, temp instability, polycythemia, and perinatal asphyxia

What are the 2 types of IUGR?

Are their problems early or late in pregnancy?

Signs/symptoms of each?

Causes of each?

Complications of each?

Early-onset or symmetric IUGR - results from in first trimester.  Weight, length, and head circumference are decreased to relatively the same extent.

Major causes - chromosomal, malformation syndromes, teratogenic, intrauterine infection

Complications - directly related to underlying cause

Late-onset or asymmetric IUGR - decreased size beginning in 3rd trimester

Head circumference is normal, weight/length decreased

Major causes - poor maternal nutrition, placental vascular dz (pre-E, toxemia), maternal illness (chronic HTN, renal dz, anemia)

complications - related to degress of placental-fetal perfusion, may cause perinatal asphyxia, hypoglycemia, polycythemia-hyperviscosity, or death

Post-term infants

defn

signs/symptoms

at what length post-term is there an increase in mortality?

defined as delivery after 42 weeks from LMP

signs/symptoms - placental insufficiency --> hypoxia, increased meconium staining, increased birth weight, no lanugo, decreased or absent vernix, loose skin, long nails, lots of scalp hair, white, desquamating skin

mortality increased if delivery is more than 3 weeks after term

Large for Gestational age infants

defn

mortality rates increase at what weight?

significant causes

higher incidence of?

infants weighing above the 90th percentile for gestational age

mortality increases at >4000g

factors - maternal obesity and diabetes

higher incidence of birth injuires, congenital anomalies, and mental/developmental retardation

early-onset neonatal sepsis

defn

infxn acquired from where?

risk factors

multisystem or focal?

most common organisms

prevention

defn - infection before or during delivery, usually manifesting in 1st week fo life, majority in first 24 hours

acquired from colonized maternal genitourinary tract - from either transplacental or ascending infection

RFs - prolonged rupture of membranes (>18 hours); chorioamnionitis - maternal fever, foul-smelling amniotic fluid, uterine tenderness, maternal leukocytosis, fetal tachycardia; prematurity

multisystem (pneumonia, sepsis common)

Organisms - GBS, enteric (primarily E coli), H flu, Listeria monocytogenes

prevention - vaginal/rectal screening cx at 35-37 weeks; high-risk patients receive intrapartum antibiotic prophylaxis

Late-onset neonatal sepsis

defn

infxn acquired from where?

multisystem or focal?

most common organisms

diagnostic terms

infection occurs from 7 days to 90 days after birth

infxn acquired from caregiving environment

usually focal (consider meningitis)

organisms - coag-neg staph, staph aureus, candida, gram-negatives, anaerobes, GBS

diagnosis - temp instability (decreased temp actually more common), poor feeding, vomiting, diarrhea, abd distention, jaundice, liver dysfx, petechiae, bleeding, apnea, resp distress, cyanosis, pallor, tachy/bradycardia, hypotension, decreased UOP, irritability, lethargy, hypotonia

Next step in management of neonatal sepsis

history focus

labs

other workup

must perform a full infection evaluation, with immediate institution of broad-spectrum antibiotics

history - maternal history, prenatal course, L/D records, postpartum course

Labs - CBC - neutropenia more common than neutrophilia, thombocytopenia is non-specific; suggestive of infxn - immature: total neutrophil count of >0.2

document positive blood culture

urine culture by sterile cath or suprapubic aspiration

chest xray

consider LP if infant symptomatic or blood culture positive (includes asymptomatic infants of mothers w/chorioamnionitis)

What antibiotics should be used for prophylaxis pending culture results?

early-onset sepsis

presumptive meningitis

late-onset infxns

further workup once antibiotics started?

early-onset sepsis - amp + aminoglycoside (often gent)

presumptive meningitis - meningitic doses of amp + 3rd gen cephalsporin (cefotax).  Aminoglycosides don't concentrate enough in CSF, listeria/enterococcus are resistant to cephalopsorins, so include amp)

late-onset infxns - msut cover coag-neg staph, so substitute vanc for amp, + aminoglycoside (again, often gent)

once organism and sensitivities id'd, switch to more appropriate drugs.  Must treat at 7-10 days or 5-7 days after clinical improvement

repeat blood cultures at 24-48 hours after start of treatment to document sterility

TORCH infections - T

Organism

Acquired/severity

Signs/sx

diagnosis

treatment/outcome

toxoplasma gondii

acquired thru maternal ingestion of contaminated undercooked or raw meat, or exposure to cat feces. Most severe if mother is affected in first trimester; more easily transmitted in 3rd trimester

Signs/sx - chorioretinitis, hydrocephalus, intracranial calcifications (toxo triad), hepatosplenomegaly, prematurity, IUGR; majority asymptomatic

Dx - PCR of B1 gene for T. gondii in amniotic fluid if evidence of infxn in mother; best test in infant is IgM ELISA

Tx - spiramycin to prevent fetal infection, if US shows fetal infxn, pyrimethamine + sulfadiazine + folinic acid

Outcome - poor w/delay in dx and tx. Chorioretinitis may lead to visual problems, blindness, calcifications may lead to seizures or developmental delay, including MR

TORCH infections - O

which organisms

Syphilis

Varicella zoster

Parvovirus B19

HIV

TORCH - syphilis

organism

how acquired/severity

signs/sx

diagnosis

treatment/outcome

treponema pallidum

100% vertical transmission; fetus considered to have 2nd stage syphilis.  Severity is correlated w/diagnosis and appropriate maternal treatment; wo/treatment, fetal/neonatal death can occur.

Early signs (<2 yo) - IGR, hepatosplenomegaly, jaundice, persistant nasal drainage, chorioretinitis, nephrotic syndrome, periosteitis, osteochondritis, mucocutaneous lesions (palms/soles, may desquamate)

Late (untreated) - rhagades (linear scars from anus, nares, mouth), saddle nose, saber shins, Hutchinson triad (notched peg shaped upper central incisors + interstitial keratitis + 8th nerve deafness)

Diagnosis - screen w/VDRL or RPR, confirm w/treponemal test (FTA-ABS or MHA-TP); most accurate - dark field microscopy

Tx - treat all infants w/highly probable diagnosis: 

1) nontreponemal test at least 4X greater than mother's

2) physical, laboratory, and radiographic dz in infant

3) +VDRL in CSF or elevated CSF prot or WBC

4) placental or umbilical cord + w/direct immunofluorescence

treat w/penicillin G 100000-150000 U/kg/24 hrs q12 (q8 after week 1) or procaine penicillin 50000 U/kg/day IM for 10 days

adequate tx of mother (penicillin at least 4 weeks prior to delivery) does not require infant treatment

Outcome - VDRL and RPR should decrease by 3 mo and negative by 6 mo; retreat if still active. If neurosyphilis, repeat CSF q6 months.  Re-treat as necessary.  Infants symptomatic at birth can develop late congenital syphilis

TORCH - VZV

how acquired/severity

signs/symptoms

diagnosis

treatment/outcome

Varicella infxn in susceptible mother early in pregnancy leads to congenital varicella syndrome; transplacental infxn at delivery leads to neonatal varicella.  Shingles causes neither.  Greatest fetal risk at 6-12 weeks (development of limb buds) and 16-20 weeks (maturation of eye and brain)

Signs/sx - cicatricial skin lesions (scarred primary lesions), limb hypoplasia and atrophy, club foot, microcephaly, IUGR, mental deficiency, seizures, chorioretinitis

Dx - maternal history and fetal US/newborn exam; VZV-specific IgM and IgG in cord blood

Tx - once maternal infxn is present, VZIG will not protect fetus; acyclovir to mother w/severe dz.  Acyclovir of no value to infant after birth since virus does not actively replicate.  Up to half die in early infancy; wide spectrum of severity for mental deficiency and seizures.

TORCH - Parvovirus B19

how acquired/severity

signs/symptoms

diagnosis

treatment/outcome

acquried via primary infxn from respiratory route

Greatest fetal risk prior to 20 weeks - virus causes lysis of RBC precursors --> transient RBC aplasia

Signs/sx - most pregnancies yield normal newborns.  Most common adverse outcome is nonimmune hydrops fetalis from severe fetal anemia

Dx - best initial test is specific IgM or rise in titer of IgG.  Most accurate test is PCR for viral DNA in amniotic fluid, fetal blood, or fetal tissue.

Tx - not established.  serial US + AFP w/possible intrauterine transufsion for severe hydrops.  Otherwise, exchange transfusions after birth.  Outcome varies; most do not have hydrops and do well.

TORCH - HIV

how acquired/severity

signs/symptoms

diagnosis

treatment/outcome

acquired from HIV infected mother by transplacental infxn, exposure to blood during labor/delivery, or contaminated human milk.  Severity related to maternal viral load; highest transmission correlates to maternal HIV RNA viral load at delivery.

Signs/sx - usually asymptomatic at birth, may have lymphadenopathy, hepatosplenomegaly, failure to thrive, pneumonia, oral candidiasis

Diagnosis - PCR for HIV DNA at birth, 1, and 4 months; 2 samples positive - infant has HIV.  All infants will be seropositive via transplacental passage of antibodies until 18 months (use ELISA and Western blot thereafter)

Tx - prevention.  Elective C-section prior to ROM, no breast milk, treat mother with oral zidovudine (ZDV, AZT) prenatally and with IV ZDV intrapartum.  Begin infant on ZDV immediately after birth for at least 6 weeks or when disease absence is established.  Outcome correlates to decrease in maternal viral load during labor/delivery w/appropriate use of combination antivirals (only anti-retroviral contraindicated in pregnancy is efavirenz)

TORCH - R

organism

how acquired/severity

signs/symptoms

diagnosis

treatment/outcome

Rubella virus (RNA virus)

acquired via respiratory tract spread; then viremia and intrauterine transmission.  Gestational age is the most important determinant of effects; worst in first trimester

Signs/sx - most have no problems at birth, but years later: IUGA w/postnatal growth failure, blueberry-muffin spots on head/neck/trunk, sensorineural deafness, congenital heart dz (w/infxn in first 8 weeks), PDA, cataracts

Diagnosis - prenatal - documented seroconversion in mother at start of pregnancy; rubella-specific IgM in mother 7-14 days after a rash illness.

Infant - best initial test - detection of rubella IgM in cord blood or increasing IgG titers over time; most accurate - isolate virus from newborn's blood, nasopharynx, CSF, or urine by PCR for viral RNA

Tx - congenitally infected children are contagious for up to a year unless repeated cultures are negative.  Primary prevention w/vaccine.  Outcome - more than 25% have some degree of MR, w/smaller numbers showing behavioral/neuro problems and autism

TORCH - C

organism

how acquired/severity

signs/symptoms

diagnosis

treatment/outcome

cytomegalovirus

acquired via close contact w/infected secretions, vertical transmission via transplacental, intrapartum, and breast milk; horizontal transmission via contact w/contaminated saliva, urine, blood.  severity - higher w/primary infxn in 1st half of pregnancy; classic cytomegalic inclusion dz if infected around time of conception

signs/sx - majority asymptomatic, but still at risk for late sequelae - IUGR, prematurity, hepatosplenomegaly, jaundice, acute hepatitis, petechiae and purpura (thrombocytopenia), microcephaly, periventricular calcifications, sensorineural hearing loss, chorioretinitis.

dx - best initial test - isolation of virus from infant in first 2-3 weeks of life (urine most commonly), CMV IgM or a 4 fold rise in IgG titers

tx - ganciclovir for severely affected infants; most effecteive for retinitis and hearing loss.  Outcome - few normal survivors.  Most consistent problem is profound bilateral, progressive sensorineural hearing loss.  >half have develpomental delay.  optic atrophy/severe visual defects, seizures.

TORCH - H

organism

how acquired/severity

signs/symptoms

diagnosis

treatment/outcome

herpes simplex 1 and 2

most neonatal herpes is from intrapartum transmission, but also by ascending infxn and crossing of intact membranes.  May have asymptomatic shed of virus during labor from recent infxn.  Higher likelihood and severity of infxn w/maternal primary herpes; higher if infxn in 3rd trimester and birth w/>4-6 hours of ROM.  Also higher w/fetal scalp monitors

signs/sx - prematurity, skin/eye/mouth vesicles, CNS involvement, least common is disseminated; can involve every organ but is highest in liver, adrenal glands, lungs, usually present in 1st or 2nd week of life w/signs of shock, DIC, pneumonitis, hepatitis. Encephalitis, irritability, poor feeding, seizures, lethargy.  Many die prior to any CNS symptoms.  

Dx - PCR ID of virus from vesicles, CSF, urine, stool, NP, or conjunctivae

Tx - C-section within 4-6 hours of ROM; immediate isolation, and culture of infant at 24 and 48 hours; serial CBC/liver tests; no circ until d/c and negative cultures.  Breastfeeding contraindicated ONLY if vesicles on breast.  Use acyclovir for sypmtomatic infants, sometimes prophylactically for infants of mothers w/primary lesions.  Outcome - mortality greatest w/disseminated infxn; sequelae more common w/HSV2 and w/encephalitis, disseminated dz, or seizures.