( BETA EDITION)

With
Prof. Dr Mohammed Abo El-Asrar

Edited By
El-Azhar Medical students 2012




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62

61
62 ... 60 neonates
..
system

Respiratory disease of the newborn

1- May central (central causes of respiratory distress in the new born)
Respiratory centre
,
respiration slow and irregular tachypnea
Frequent apnea
May central cyanosis.

)a

)b

)c

a- still immature R.C. :

May still immature ...So, R.C. Pre term
b- exposed to severe hypoxia
severe hypoxia
Ante natal, R.C. brain severe hypoxia
post natal or natal
c- malformations in resp. center :
Malformation in respiratory centre
d- narcotic
R.C. placenta narcotic
e- IC Hge
intra cranial hemorrhage
f- meatabolic
Metabolic disorder

Hypoglycemia

Hypothermia

May hypocalcemia, hypomagnesemia

central causes of respiratory distress New born respiratory distress
N.B.
Transient or permanent????
transient or permanent

2.

Peripheral causes of respiratory distress .

peripheral
signs of distress ... chest

Tachy pnea

Working ala nasi

Accessory muscle

Grunting
chin tug new born Terminal case only new born respiration accessory muscle
frequent respiratory centre serious hypoxia Contraction in lateral labialis muscle
attack of apnea
gasping Peripheral

Pulmonary

Extra pulmonary

1- Pulmonary
Lung
a- Alveoli
inflation alveoli ) ( surfactant -1
hyaline membrane disease
1ry atelectasis 1ry collapse One lobe or more inflation alveoli -2
Mild respiratory

respiratory distress pneumonia alveoli infection -3

gas exchange 10 % alveoli distress

b- extra-alveolar as :
amniotic fluid airway lung ... aspiration -1

meconium Iatrogenic tension pneumo thorax extra alveolar -2
approximation of fingers new born ampo ampo bag respiration
tension pneumo thorax .. [ ] ,
c- congenital emphysema :
congenital emphysema 2- Extra pulmonary
Lung

1.

Bilateral post choanal atresia.

nose .. surgery oro-pharynx

2.

May be laryngomalacia or laryngotracheomalacia.

collapsing cartilage .. larynx trachea -

3.

May vocal cord paralysis.

4.

May laryngeal web.

5.

. Tracheo-esophageal fistula
aspiration airway ... ... esophagus trachea . ,

6.

Gastro-esophageal reflux.

7.

Diaphragmatic hernia or paralysis.

ENT
hyaline membrane disease
Hyaline m embrane disease
= Respiratory distress syndrome type one
respiratory distress syndrome
Type one & type two
idiopathic respiratory distress syndrome hyaline membrane disease Type one
Transient tachy pnea of the newborn Type two

Type one
[ mucous type one ] Type two alveolar cell ... alveoli ... dry alveoli secretions surfactant type two alveolar cell Inspiration
.. sphingomyelin Phospholipid lecithin surfactant cortisone supra renal lecithin
35 weeks gestational age cortisone supra renal 37 surfactant :
Risk factors
respiratory distress type one surfactant a)

Pre term
surfactant 37 -

surfactant 30 hyaline preterm 36

5

Infant of diabetic mother

)b

1- May be preterm
2- Hyperglycemia
fetus hyperglycemia pancreas ( ( ) fetus water
soluble placenta )
antagonist effect on cortisone
So, no ability of conversion sphingomyline to lecithin
Ante natal or natal hypoxia

)c

supra renal hemorrhage cortisone surfactant
Cesarean section

)d

36 surfactant )vaginal ( uterine contraction , stress cortisone 3 Level surfactant

Pre term stress
(
, , )
Pathophysiology
hyaline membrane disease
intra uterine alveoli collapsed Mucous type one 35 cortisone surfactant alveoli .. dry 2layers Inflation alveoli surfactant alveoli mucous secretion alveoli secretions inflation surfactant Inflation
Inflation O2
PO2 CO2So, CO2 respiratory acidosis
PH ... Hypoxia anaerobic metabolism organic acidMetabolic acidosis
respiratoryrespiratory and metabolic acidosis mixed
- hypoxia V.D. blood vessels Pulmonary arteryV.C.

acidosis hyper capnia hypoxia alveoli ... lung .... Viscous circle ..... More vaso constriction pulmonary V.D.
Signs of peripheral respiratory distress limit hypoxia slow and irregular respiration R.C. hypoxia frequent attacks of apnea
Diagnosis
clinically
a)

History of one of the risk factors

cesarean section hypoxia Placental infarction DM 35 36-35

b)

signs
( no complaint(

1- Signs of distress Of lower respiratory tract (May cyanosis or not)

2- Auscultation:
auscultation
- air entry is markedly diminished
- bronchial breathing as most alveoli
- fine crepitation
all over the chest in elastic alveoli
Respiratory depression ..Etc. emergency auscultation
Investigations
hyaline membrane disease Peripheral signs of distress
) ( saline tracheal secretion shake bubbles surfactant ) (
test
X-ray bubbles grade hyaline membrane disease
Grade 4
grade four alveoli lung
Grade 3
grade three airway
Grade 2
grade two ground glass appearance inflated alveoli Lung
Grade 1
grade one bronchopneumonia
PH CO2 PO2 Blood gases

 diagnosis
Management
Preventive avoidance of the cause.

1.

Avoidance of causes of prematurity.

Diabetic mother .

good management of DM Avoid ante natal and natal hypoxia

screening
Avoid cesarean

item ... badly time cesarean section ( Or still immature ... lung mature (DM
)a
)b

gestational age

amniotic fluid lecithin sphingomyelin

L/S ratio
- 2 surfactant

2 surfactant 2 .. dexamethasone placenta

fat soluble water soluble maturationLung
hyaline membrane disease

1- ICU
neonatal ICU
)a
)b

source of infection

New born heat regulating centre

...
Hypo thermia 37
40 % humidity airway dryness airway
)c

)d

O2 therapy

distressed 2/3 IV fluids non distressed 2/3

hypoxia ADH hyper volemia
oral feeding distressed Proper antibiotic therapy Infected

2- give surfactant :
surfactant surfactant ... surfactant ... 2 L/S endotracheal tube 3- ttt of hypoxia , hypercapnia , acidosis
hypoxia & hyper capnia alveoli Inflation surfactant b O2 therapy

)a

mechanical ventilator

)b

Mechanical ventilator
60 CO2 .... 50 PO2 ... 7.2 PH
apnea
Respiratory failure =
) ( O2 toxicity 80 60 PO2

Retinopathy

Broncho-pulmonary dysplasia
acidosis
Na bicarb acidosis mechanical ventilator -

4- Good care of baby in ICU :

Oral nutrition good care of baby in ICU
Vit. K
60 % PO2 ventilator
Hb F Hb F exchange transfusion
O2 Hb A
Complications of NIUC
Neonatology
Prognosis
facilities of ICU prognosis of hyaline membrane disease

Infection control of ICU

Experience of personnel


50 % 50% 1
5 %

95% 2-5

Respiratory distress type two

Called transient tachy pnea of the new born
3 tachypnea

persistent of lung secretions

 preterm full term surfactant airway secretions by normal vaginal delivery Uterus vagina squeezing lung secretion
cesarean sections
signs of distress secretions coarse crepitation & sonorous rhonchi mask of O2
Meconium aspiration syndrome


Meconium feces ... fetus defecation intrauterine life defecation intrauterine
hypoxia relaxation of anal sphincter Intrauterine life amniotic fluid amniotic fluid meconium meconium Mouth nose
secretion naso & oro pharynx meconium airway partial obstruction complete obstruction
......distressed ventilator alveoli partial obstruction
pneumo thorax
alveoli complete obstruction Meconium absorption collapse
Neonatology
....

meconium Meconium vagina amniotic fluid


1- cephalic presentation

cephalic truck birth canal trunk trunk .. spontaneous respiration
support perineum nose naso-pharynx meconium 2- breech presentation

breech vagina trunk respiration
aspiration Meconium 62 63

10

Neonatal apnea
central respiratory depression central respiratory depression
Causes
1.

May mother take narcotics

addicts

2.

May RC still immature

RC compression intra cranial hemorrhage malformation of RC PT

pontine hemorrhage
3.

May sepsis
encephalitis meningitis -

4.

Any peripheral cause of respiratory distress

severe hypoxia -

5.

Metabolic causes all

N.B.
NEC = necrotizing enterocolitis = severe sepsis cause necrosis in gut .
sepsis
Management
resuscitation
Hypoglycemia in the new born
...
hypoglycemia
hypoglycemic level 35 mg /dl glucose level 3 -1
40 mg /dl glucose level 24 3 -2
45 mg /dl glucose level 1 day -3
hypoglycemia
Causes

glycogen stores in liver

.1

endocrine hyperinsulinemia

.2

blood glucose counter regulatory hormones hypoglycemia

counter regulatory hormones
Excess requirements
In born error of metabolism

.3

.4
.5

1.

glycogen stores as in PT & IGR

9 .... Preterm -

11

organogenesis 3

Preterm .... stores 3

2.5-3.5 full term 37 called intrauterine growth retardation 2.5

glycogen stores nutrition
2.

Excess insulin

a- RH _ncompatibility
As anti D cause stimulation of islets cells of pancreas ... RH incompatibility
so, more insulin
Hypomagenesemia , hypo glycemia & hypo calcemia
b- Infant of diabetic mother
glucose <<< Infant of diabetic mother
c- islet cell hyperplasia
rare islets cell hyperplasia
d- Beckwith-Wiedmann syndrome:
increase insulin Islets cells hyperplasia
3.

counter regulatory hormones

GH, thyroxin , cortisone ... pan hypo pituitrism Frequent attacks of hypoglycemia

4.

Excess requirements

a- infection:
glucose Infection glucose Organism infection supplementation
glucose ... indicate severe sepsis Hypothermia b- Polycythemia:
Excess consumption of glucose glucose RBCs WBCs platelets RBCs
So, no endogenous synthesis ... non nucleated cells RBCs glucose c- Tissue hypoxia

36 ATP 1 gram kreb's cycle give 12 ATP 1 gram glycolysis

3 gram glycolysis 36 ATP glycolysis kerb's cycle kerb's cycle O2 tissue hypoxia hypoglycemia more consumption of glucose

12

So, one of causes of hypoglycemia RDS congenital cyanotic heart disease , HF, .etc.
5- In born errors of metabolism :
galactosemia glucose ..... glycogen storage disease In general infant of diabetic mother
Infant of dia bet ic mother

Hyperglycemia DM
most common type two oral hypoglycemic Oral hypoglycemic is absolutely contraindicated during pregnancy
hypoglycemia insulin phobia hyperglycemia Maternal hyperglycemia during pregnancy
Pathophysiology

fetal hyperglycemia placenta Mono mono saccharide glucose
.. ..
1- multiple congenital anomalies
Period of organogenesis 3 Cause multiple congenital anomalies in baby ... teratogenic effect glucose As congenital heart disease ..Etc.
2- hyperinsulinemia
Fetal hyperglycemia Cause fetal hyper insulinemia

1- insulin is an anabolic hormone

anabolic hormone

glycogen synthesis, lipid synthesis & protein synthesis
4 Macrosomia phospholipid brain

1- PT
uterus stretch 35 ) 4 ( 4 ... So, preterm.. premature delivery premature uterine contraction
2- Birth injuries
birth canal birth injury vaginal full term
2- Insulin has antagonistic effect on cortisone RDS I

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

13

3- Insulin stimulation of erythropioesis Polycythemia

Stimulation to erythropioesis intrauterine that occur in spleen and liver
Plethoric face ... RBCs count ... BM
RBCs
a- Thrombosis
thrombosis blood viscosity
b- Jaundice even Kernicterus
jaundice indirect bilirubin RBCs May kernicterus saturation level Indirect bilirubin 4- After delivery Hypoglycemia

hypoglycemia
True convulsion hypoglycemia (epinephrine ( Due to peripheral vasoconstriction +
poor suckling Poor reflexes ,, central depression Cyanosis of R.C. pathophysiology
Clinically

1.

Large More than 4 Kg.

2.

Plethoric features.

3.

Manifestations of hypoglycemia.
infant of diabetic mother
Complications

1.

Multiple congenital anomalies, congenital heart disease. pelvic and lower limb anomalies
Due to embryonic hyperglycemia.

2.

Macrosomia birth injuries & prematurity.

3.

RDS type one.

4.

Polycythemia thrombosis.

5.

Neonatal jaundice & kernicterus.

6.

post natal hypoglycemia

Management of infant of diabetic mother & hypoglycemia
hypoglycemia risk factors
As DM mother , preterm, IGR , RH incompatibility

hypoglycemic level or not One of risk factors hypoglycemic

14

:
Start oral feeding as early as possible
frequent breast feeding to oral intake of milk or glucose

24 ) (
) ( ) ( ..
..
) ( glucose IV line Hypoglycemia 24
IV glucose 24 ( )

cortisone glucose IV glucose As counter regulatory hormone
glucagon hypoglycemia specific antidote as it is a life saving drug in hypoglycemia
Ca gluconate , Mg sulphate hyperinsulinemia hypoglycemia
1
Infant of diabetic mother H.F.

Congenital heart disease

Polycythemia
congestive heart failure hypervolemia
2
glucose hyper insulinemia
hypoglycemia hypoglycemia
in secretion 9 ...

Revision o f hematology in new born
Bleeding in the new born
Newborn hematology
Causes

bleeding

No vasoconstriction vessels vascular cause

.1

platelets

.2

Coagulation factors defect .... coagulation factors

.3

Intrinsic
12, 11, 9 and 8

Extrinsic

15

7,

Common pathway
10, 2 and 1
newborn ... Pathway factors
1-Vascular cause

vessels fat preterm

So, fragile capillaries in preterm
2-Platelets defect
1.

May defect in function thromboasthenia.

hereditary
Von-Willbrand factor deficiency
glycoprotein 1 b receptors vessels wall platelets
Burnard soluir disease
Called Burnard soluir disease May glycoprotein 1b
Glanzman's disease
deficient ADP glycoprotein 2B, 3A platelets
Glanzman's disease
Aspirin
of COX Placenta Teratogenic effect
So, no ADP No platelets aggregation

2.

May defect in platelets number thrombocytopenia.

a- decrease in synthesis
bone marrow ... synthesis STORCH infection sepsis depression to bone marrow - Or TAR syndrome
TAR thrombocytopenia with absent radius -

absent autosomal recessive gene + Thrombopiotein receptors stem cells radius

b- Excessive destruction
1- Antibosies
idiopathic thrombocytopenic purpura antibodies transient Idiopathic thrombocytopenic purpura placenta Ig G antibody SLE
2- Isi immune thrombocytopenia
RH negative positive antigen Platelets -

16

 antibodies positive negative 3-Coagulation factor defects

hemophilia
X-linked recessive gene 8 Type AX-linked recessive gene 9 Type Bautosomal recessive gene 11 Type C intrinsic pathway factors
Factor one afibrinogenemia or dysfibrinogemia.
Congenital factor 7 deficiency extrinsic pathway defect.
vitamin K 1972
Hemorrhagic disease of the newborn
If DIC consumption of coagulation factors + platelets thrombocytopenia.

Hemorrhagic disease of the newborn
.... circumcision coagulation factors causes

Vitamin K

1.

Maternal deficiency of Vitamin K.

So, stores of vitamin K in baby

2.

Vitamin K need bacterial flora.

Liver vitamin K Still immature bacterial flora -

3.

May liver is still immature.

Diagnosis ( C/P + Investigation )
Epistaxis, at site of IM, passing of blood in stool, at site of umblical cord
Intracranial hemorrhage

intrinsic 11, 10, 2 ... prolonged PT 2, 7, 9 and 10 So, prolonged PTT ... common
Prevention
Intra muscular .. K 10 mg 4- 6 .. vitamin K 1mg Intra muscular 2-5

17


3 vitamin K vitamin K fresh frozen plasma or fresh blood Anemia of the new born
A - Physiological anemia
Partial tissue hypoxia Lung O2 placenta Hb F Hemoglobin intrauterine

1.

Poor O2 dissociation

2.

RBCs that contain Hb F

60 ... 120

Normal Polycythemia intrauterine More RBCs spleen Liver intrauterine 18-22 gram % hemoglobin

Hb RBCs synthesis erythropiotein O2 ... Lung 9 gram % Hb RBCs
bone marrow Hypoxia 45 Physiological anemia is more severe in preterm why
RBCs ... Which is an antioxidant ... vitamin E

B - Pathological anemia
Causes
anemia in general
hematology
1.

synthesis
requirements bone marrow requirements STORCH infection or sepsis

2.

Excess loss

hemolysis >>> Defect in RBCs itself :

Cell membrane as spherocytosis.

Enzymatic deficiency G6PD.

May abnormal Hb alpha thalassemia.

Extra corpscular causes.

18

Antibody RH or ABO incompatibility

Or autoimmune hemolytic anemia of mother

Non immune as toxins as in sepsis .

May excess loss

a- Placental Hge
umblical cord Placenta placental hemorrhage b- Feto-fetal transfusion
Called feto-fatal transfusion .. ( ( placenta 2 c- Feto-maternal transfusion
separation of placenta ) ( 10 cm ... 5 cm 5 cm -

Excess loss after delivery.

Cephal hematoma.

Intra cranial hemorrhage.

Bleeding umblical stump.

Bleeding
frequent sampling ) ( iatrogenic anemia
Investigation
Synthesis or loss ??
CBC + Retics >>>

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

If retics & Hb >>> so, hemolysis
Treatment
Treatment of underlying etiology + may packed RBCs transfusion .
Cyanosis in the newborn
..
Causes
1-Respiratory centre depression.


Slow and irregular respiration + frequent apnea
2-Peripheral respiratory distress.
>>> Pulmonary or extra pulmonary.

Signs of respiratory distress
3-Congenital cyanotic heart disease .
19

a- Transposition of great arteries

Left ventricle Pulmonary right ventricle Aorta
"TGA" Transposition of great arteries
b- Single ventricle (no inter ventricular septum)
c- Tricuspid valve atresia
left side foramen ovale Tricuspid valve atresia
d- Pulmonary atresia
... Pulmonary atresia
e- Fallot tetralogy very rare
4-Methemoglobinemia.
5-Metabolic causes.
64 63

Fever in newborn
2 important causes of fever in the neoantes

Dehydration fever.

Neonatal infections.
Dehydration fever
Causes of dehydration fever
: 3

1- Delayed breast milk production.

Initiate breast secretion suckling
. ... 2- Excessive sweating.
sweating ... ) ( ... ...
water loss
3- Over clothing especially in hot weather.
Clinical picture
1.

High temperature.

20

if delayed breast milk

38- 38.2 Low grade fever

If excess sweating
40 High grade fever

2.

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 output
Types of dehydration in newborn
sweating Hypertonic dehydration newborn
dehydration salts Loss of water
Treatment
Correction of dehydration

Prognosis
So bad

Mat ernal disease a ffecting the newborn

1- Neonatal infection as STORCH infection.

Organism 2- D.M.
3- Toxemia of pregnancy, hypertension.
termination of pregnancy placental insufficiency Hypoxia intrauterine due to infarction in placenta ... Preterm 4- Auto immune disease of the mother.
) 3 ( transient IgG As ITP, autoimmune hemolytic anemia, myasthenia gravis, auto immune thyrotoxicosis and SLE
5- Phenyl ketonuria.
diet Phenyl alanine restriction

As mental affection phenyl alanine

6- Deficiency disease in mother.
So, stores as in
Vitamin D.
IDA IDA < 6 months.
21

Low birth weight

Introduction
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
low birth weight 2.5 kg
1.

May preterm.
37 gestational age
NB
2.5 kg low birth weight

2.

preterm

May full term.

40 37 NB
post date 40
3-3.5 plus or minus 0.5 kg Intrauterine growth retardation If full term < 2.5 kg
1 kg & 900 gram

a)

Preterm 60 %.

b)

IGR 40%.
prematurity
Causes of prematurity

50 % of prematurity idiopathic.

50 %

1- High risk pregnancy

) ...... 4 3 2 ( 4 kg ) ... 4 3 2 ) capacity Uterus Prematurity Uterine contraction stretch distention

2- DM during pregnancy
a- macrosomoia large baby
preterm 4.5 , -

22

b- or complication of DM during pregnancy

diabetes Nephropathy , DKA

etc

termination of pregnancy
3- Hypertension during pregnancy
toxemia of ) 30 ( termination of pregnancy severe
pregnancy
4- Premature separation of the placenta
Ante partum hemorrhage placenta placenta privia
Causes of IGR


1.

Chromosomal abnormalities.
As Multiple congenital anomalies

2.

May STORCH infection .

anomalies

3.

May teratogen to mother anomalies.

4.

Any cause of placental insufficiency.

full term with IGR Preterm Clinically
: 900
DD between PT & IGR ( FT )
) (
1- Assessment of gestational age
...

a)

From history

Date of last menstrual period

accurate ...

Date of onset of fetal movement.

18-20 ) primi garvida (
16- 18 ) multi para (
primi gravida

b)

Antenatal examination
age Fundal level fundus of the uterus gestational age false impression

c)

Ante natal investigations .

U/S ( sonar )

23

bi acromion diameter bi parietal diameter of the skull NB.

.. 37 37 .

Amnio-centesis.

- For lung maturity L/S ratio

- For kidney creatinine.
2- At birth.
A - Physical signs
1- Head

a- Hair
preterm ... : Full term b- Ear
full term formed cartilage of ear preterm formed
2- Nipple of the baby
diameter

If > 3 mm (0.3 cm ) full term

If = 3mm (0.3 cm ) or less Preterm

3- Genitalia

If female

full term labia majora cover minora pre term majora not cover minora

If male

full term scrotum testis pre term few rugue undescent 4- Legs
preterm 2 one ( ) no creases sole full term ( ( crease cross pattern 2 B - Neonatal reflexes neurological evaluation

preterm
criteria
Handicaps & complications of prematurity

24

( Neonatology (
1- Respiratory handicaps.
a)

RC still immature central respiratory distress and apnea.

b)

RDS type two.

c)

Weak respiratory muscle.

shallow respiration , stagnant secretion secretion weak cilia repeated chest infections

d)

Blood vessels.
hemoptysis Pulmonary capillaries fragile

2- CVS.
a)

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

delayed closure of PDA

.
:
O2 sensors endothelium DA
PGE2 endothelium PO2
relaxation of the smooth ms around DA still patent
intrauterine
b)

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

3- Heat regulatory system .

brain heat regulatory centre
If temp heat loss + production .
generalized hypotonia & muscle weakness -1
heat production muscle contraction
flushing VD peripheral vessels sweating dehydration fever
Muscle heat production By shivering heat regulatory centre .... -2
heat loss S.C. fat
heat loss
0.5 1.7 surface area So, more heat loss
4- Liver
Contain stores as CHO, iron , vitamin D , vitamin K .
stores
A So, decrease in all stores :

25

CHO hypoglycemia.

Iron iron deficiency anemia before 6 months .

Vit. D rickets before 6 months.

Vit. K hemorrhagic disease of the newborn.

B Also, liver secrete coagulation factors so, here liver is still immature .
- So, PT & PTT ( all factors )
C Also, bile salts .
( Steatorrhea ( fat fat digestion
Less fat content ... Colestrum
D Also, enzymes still immature
as glcouronyl transferase enzyme. + Z & Y protein still immature So, physiological jaundice.
14 ) (
5- GIT.
a)

Muscles of mastications are weak.

So, weak suckling.

b)

Also, muscle of the pharynx weak swallowing.

c)

Small capacity of stomach.

d)

Malnutrition & mal absorption as bile salts & digestive enzymes.

e)

GIT motility problems as exaggerated gastro-colic reflex

) ( , , suckling colon motility - Or gastro-esophgeal reflux
GIT
hypoglycemia GIT

6- Kidney.
Still Immature GFR. , glomerular & tubular function
So, failure of the kidney to concentrate urine.
7- Bleeding
Why ???

coagulation factors , vitamin K ( liver still immature ) .

Fragile blood vessel .

8-Immune system dysfunction immunity

passive immunity
3 IgG 3

Also, active immunity .

) Liable to any infection ( sepsis immature
complications

1.

Hypothermia of the preterm.

2.

Hypoglycemia in preterm.

26

Why Hypoglycemia in PT ???

1) Stores (CHO).
2) Hyper insulinemia if infant of diabetic mother.
3) Counter regulatory hormones.
4) consumption as
infection and hypoxia
5) Intake.
6) Absorption.
NB. IGR compliacations as PT
Management of low birth weight
1.

Prevention preventable.
- Avoidance of causes
N.B. Normal glucose level in newborn as in adult
.


... ,

full Cesarean section Avoid badly time Cesarean section

)a
)b
)c

)d

term
2.

Curative .

a- Neonatal ICU.
..
infection

O2

% 40 60

b- Feeding .
.... Oral feeding
1- Onset :
hypoglycemia as soon as possible
2- Method


a- capable of suckling & swallowing:
breast or bottle swallow suckling (
) breast

27

bottle
b- If only swallowing
formula breast milk
c- if no ablility to swallow
Naso gastric tube
3 - Type of feeding
1- Breast milk.
..... 2- Artificial milk. PT formula
Cysteine + taurine full term Preterm formula Methionine to cysteine & taurine brain growth

) ( cysteine and taurine preterm 3- If preterm formula not available.
... Give full term formula 60 45 ,,,, IV fluid naso gastric tube As in intracranial hemorrhage respiratory distress
4 - Amount of milk
.... 5cm
IV fluids requirements
60 ml / kg start at 1st day of life Full term

80 ml / kg Preterm

150 ml /kg / day maximum 10- 20 ml /kg

3- Prevention of infections .
( fully steralized immunity )
Give broad spectrum antibiotics Penicillin + gentamycin
May immunoglubin needed
4- Give

Vitamin K.

Vitamin E.

Vitamin D & iron.

stores ) ( 65 64

Birth injuries

28

Head injuri es
1.

Caput succedaneum

scalp presenting part of the scalp edema Called cephalic presentation

,,, skull ) Cesarean section ( birth canal scalp edema Obstruct venous drainage
birth canal edema cephal hematoma

Sub-periosteal hemorrhage

Normal at birth
Maximum at birth caput succedaneum

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

scalp cross suture lines caput succedaneum
- due to obstructive labor
Just reassurance of parents regressive course course 2.

Cephal hematoma

Also, cephalic delivery.

Obstructive labor.

sub-periosteal hemorrhage Forceps intra cranial hemorrhage skull Not cross suture line Limit swelling Complications
1.

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

2.

Hemolysis of its RBCs indirect billirubin.

3.

May 2ry infection.

Iatrogenic blood vessels pressure hematoma drainage
drainage
organism drainage Infected hematoma

4.

healing by fibrosis & pathological calcification .

Disfigurment of skull
Investigations

Brain U/S.

Intra cranial hemorrhage

Also, CT & skull X- ray.

skull
Treatment

29

 ,
1.

If anemia packed RBCs.

2.

If billirubin phototherapy, even exchange transfusion.

3.

Antibiotics to treat 2ry bacterial infection.

2ry infection bacteremia

4.

fibrosis & calcification

,,, fibrinolytic system blood clot
) .. (
resorption & resolution
3. Intra cranial hemorrhage
Causes

1.

Birth injuries.

2.

Hypoxia vaso dilation of cerebral vessels

So, incidience of intra cranial hemorrhage

3.

Vascular anomalies as congenital aneurysm of cerebral vessels.

4.

May hemorrhagic disease of the newborn.

5.

Bleeding tendency.

6.

Prematurity.

Fragile blood vessels.

Liver immature coagulation factors.

Vitamin K stores.
Clinical manifestations
Intra cranial hemorrhage

Anemia pallor

High pitched cry

Tense and bulging anterior fontanell

3
You must exclude intracranial hemorrhage

intracranial tension

1- Triad
2- Intra cranial tension

Only high pitched cry

Projectile vomiting ) not proceded by nausea)

Bulge & tense _ontanel

30

3- may poor feeding

centres
4- Loss of neonatal reflexes
5- Drowsy even _onvulsion & deep coma
6- Eye unequal pupil
Investigations

Brain sonar.

CT & MRI.
Treatment

1.
a)

Incubator
Position raise head 30 degrees

head bleeding

b)

Feeding.

If convulsion give IV fluids.

If comatosed or drowsy tube feeding.

2.

Give packed RBCs.

Vitamin K.

Fresh frozen plasma.

Or fresh blood with no packed RBCs.

3.

Convulsion give phenobarbitone

Neuro surgery
Periph era l nerve injury
1.

Erb's paralysis.
) klumpke's ( shoulder delivery -

brachial plexus injury axilla birth canal shoulder

Deltoid & biceps muscle ,, C5, 6 roots shoulder abduction
Degrees

Till 15 supra spinatus

15-90 deltoid

More than 90 upper fibers of trapizius

Flexion of elbow + supination action biceps Supination + extension at wrist joint action C5, C6 and C7 brachio radialis -

31

 action brachio radialis fibers Deltoid + biceps So,

i.

Adduction + internal rotation of the shoulder

) deltoid (

ii.

elbow extension
) biceps (

iii.

Wrist pronation + extension

) brachio radialis (
Called policeman's tip position

iv.

Here nerve

So,

Motor affection

Sensory affection Outer aspect of arm

Loss of biceps reflex

Treatment
functioning muscle
Under stretch muscle spindle,,, muscle tone
) keep ms contracted (

So

Shoulder external rotation + abduction

Elbow flexion

Wrist supination + extension

physiotherapy
2.

Klumpke's paralysis
Injury to C7, 8 and T1

small muscles of the hand supply

Dropped hand

Lost grasp reflex

May Horner syndrome

sympathetic chain
Treatemnt
Physiotherapy
3.

Diaphragmatic paralysis

May injuries to roots of phrenic nerve C3, 4 & 5

So, mainly thoracic respiration ,,,, paralysis of the diaphragm

If bilateral severe respiratory distress

Investigations

32

 By fluroscopy .... diaphragm

Treatment
Only supportive + surgical
4.

Sterno mastoid injury

Maceration and hematoma inside it later , fibrosis and calcification.

swelling tumor lymph node 6 Torticollis hard mass tumorTreatment
Surgical removal of sternomastoid

Viscera l injuries
delivery of trunk spleen

Resuscitation of newborn
APGAR score
Apgar score
(

,


Apgar Virginia Apgar
1909 1974
Medical eponym 35
)
Apgar score assessment 0 1 2 full mark 10( .. .. .. .. 2 full
mark ) 10
( ) Naso pharynx ( Apgar score 5) assessment "

1- Color
Completely pink 2 marks.

1.

Body pink & extermities blue 1 mark.

2.

Blue or pale 0.

3.

2- Movement

33

Active movement 2 marks.

1.

Generalized flexion 1 mark.

2.

3.

Floopy 0.
3- Reflex to nasal catheter

1.

Cough & sneeze 2 marks.

2.

Grimace response 1 mark.

3.

Absent any reaction 0.

grimace NB
4- Respiration

1.

Good crying 2 marks.

2.

Slow and irregular 1 mark.

3.

Apnic 0.
5- Heart rate

1.

More than 100 2 marks.

2.

Less than 100 1 mark.

3.

Arrested = less than 60 in newborn 0.

apgar -

1.

If 8 - 10 good general condition & no asphyxia.

2.

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

3.

If 4 or 3 moderate asphyxia.

4.

If less than 3 severe asphyxia.

resuscitation
) .... O2 ( -1
. Na HCO3 , Ca gluconate , glucose 10 % . ) 2 ( -2
,,, , Apgar naso & oropharynx ( post choanal atresia ( esophgeal atresia
anus pass meconium or not -

5 7 apgar ) Pinching ( ,,, ) ( sole tactile stimulation of respiration

O2 opium umblical catheter naloxone Just approximation of fingers Laryngoscope & do endotracheal tube ampo cardic massage
) ( : umblical catheter Glucose 10 % 2 - 4 cm

34

 Na HCO3 may acidosis

Epinephrin heart
(brady cardia ( Ca gluconate 100 heart rate hypocalcemia
Neonatal reflexes
1- Moro reflex

2 phases 30 15 ,,

Extension & abduction

Then Flexion & adduction

Apperance 28 weeks gestational age.

Disapperance 3-4 months.

Significance :

If unilateral local cause Erb's palsy, fracture clavicle, dislocated shoulder.

Still present after more than 4 months CP.

2- Grasp reflex

Also, in sole of foot ,,, Your thumb in palm palm

3- Rooting & suckling reflex
Rooting stimulation of the cheek around mouth and respond by turnning of the face & mouth

towards stimulus.

)b
)c
)d

If bilaterally absent may so, central problems preterm, meningitis, hypoglycemia, hypothermia.
any central cause.

)a

Suckling
hard palate 7 4- Stepping reflex
,,,, 5- Placing reflex
... under surface foot dorsum 15 6- Glabellar reflex
7- Tonic neck reflex
rapid rotation of neck to one side supine -

35

Flexion Extension of limbs

6-7
8- Neck righting reflex
Slow rotation of neck to one side trunk follow the neck .
9- Parachute reflex
Appear at 9 months & persist.
Extension of trunk & all limbs prone 10- Landau reflex
Prone position
generalized flexion head flexion Extension neck and trunk
11- Positive Babiniski sign

66 65

Hypoxic isch emic encephalpathy

... hypoxia
Either

Intrauterine

Fetal hypoxia
Etiology
hypoxia

blood O2 Lung heart .. O2 fetus umblical cord placenta wall of uterus blood vessel

A - Fetal hypoxia
1.

Maternal hypoventilation

During general anasthesia.

Heart failure.

Or carbon monoxide poisoning.

2.

Maternal hypotension blood to uterus

Spinal anasthesia.

Dehydration

Compression of aorta or IVC.

blood to uterus uterus

supine
3.

Uterine causes
As in uterine tetany

36

) ( oxytocin Compress uterine vessels uterine contraction Oxytocin 4.

Placental causes

Premature separation.

Any cause of placental insufficiency.

5.

Compression of umblical cord

B - Extra uterine
All causes of cyanosis in the newborn
...

1.

Central respiratory distress.

2.

Or peripheral respiratory distress.

Pulmonary.

Extra pulmonary.
Clinical pictures
If intra uterine hypoxia.
1. IGR

2. Slow & irregular fetal heart rate
: 3. Meconium stained amniotic fluid
Relaxed anal sphincter ........ hypoxia
: ) vagina ( amniotic fliud
4 ... PH monitor ) ( baby scalp Probe
4. Severe acidosis indicate hypoxia.
,, aspiration of meconium : Hypoxia 5. Apnea & slow irregular respiration.
Heart rate or arrest, cyanosed, floppy
resuscitation apgar ) ( : 6
6. Encephalopathy.
7. If more than 24 hrs severe brain edema and may death.
8. Convulsions
neuronal cells
37

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

c)

If convulsion anti convulsion

Investigations

Prognosis

1.

No brain damage

2.

with CP

3.

death
Necrotiz ing ent erocolitis

( NEC )
hypoxia gut ischemia -

necrosis infection gut ulcer gut mucosa necrosis So, causes of necrosis

Ischemic necrosis.

Toxic necrosis.
Clinically

1- GIT manifestations
1.

Paralytic ileus

Hypoxia or ischemia.
Toxiemia toxic ileus.

bile newborn Also, abdominal distention & constipation (no colic ) .

2.

Ulcers bleed
:
hematemesis

melena or bleeding per rectum

3.

Also, may perforation occur

Due to ischemia & infection >>> Peritonitis tenderness

2- Non GIT manifestations

38

1.

Hypoxia slow irregular respiration even apnea.

Heart rate is irregular

2.

Toxaemia
- May hypothermia, hypoglycemia , hypocalcemia, hypomagnesemia .
investigations clinically investigations
) Investigations ( triad NEC

1.

Thrombocytopenia

Sepsis bone marrow Or destruction of platelets

2.

Persistent acidosis

organic acid hypoxia

3.

Persistent hyponatremia
- As sepsis erosion of gut >> No absorption of Na
- Also , May due to supra renal hemorrhage. >>> Addison
1 , 2 & 3

4.

May blood in stool

5.

X- ray air under diaphragm

Treatment

No oral feeding, only IV fluids.

Naso gastric tube & suctioning.

Treatmetn of any complication as :

1- infection 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 rate
: 3 neonatology
1- Meconium aspiration.
2- NEC
3- HIE

39

 neonatology

65 infections

neonates 60 & 61




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