Mock Exam 6

Neonatology
ANSWER
Part One MRCPCH
Educational Materials from MRCPCH2009 for Part 1
Number of questions: 20
Score: 100 marks
Time: 30 Minutes

MRCPCH2009 SITE

ELBABA M.A.

Mock Exam Series # 6

Neonatology Test 1

MRCPCH2009 Site
ELBABA M.A.

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ANSWERS AND COMMENTS

EXTENDED MATCHING QUESTIONS
Q. 1 (20 Marks)
This is a list of organisms may affect the mother during pregnancy:
A. HIV virus
B. Hepatitis B virus
C. CMV Virus
D. Erythrovirus
E. Papilloma virus
F. Rubella virus
G. Pox virus
H. Varicella virus
I. E-coli
J. Listeria monocytogenes
K. Group B streptococcus
L. Klebsiella spp
M. Anthrax
N. Bacteroids
O. Toxoplasma gondii
P. Candida albicans
Q. Spirochetes
R. Aspergillus spp
Choose the most likely organism for each of the following scenarios:
SELECT ONE ANSWER ONLY FOR EACH QUESTION
Note: Each answer may be used more than once
1. Gram positive rods present in dairy products producing early and late onset
sepsis. Pustular skin rash is common. Meconium like stained liquor J
Listeria infection is one of gram positive bacilli producing early sepsis mainly
respiratory infection and late sepsis mainly as meningioencephalitis. It
changes the color of the Liqour and may misdiagnose as meconium
aspiration syndrome. It has a characteristic skin infection in the form of
pustules. It is sensitive to Penicillin.

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Mock Exam Series # 6

Neonatology Test 1

MRCPCH2009 Site
ELBABA M.A.

____________________________________________________________________________

2. Baby born well or unwell and may develop visual problem even after few
months and treated with Pyrimethamine and sulfadiazine for up to one year.
Mother need to be treated with Spiramycin. O
Toxoplasmosis is a common maternal infection with long term sequel on the
developing baby. It is one of the causes of blindness due to extensive retinal
affection (chorioretinitis) and neurodevelopmental delay.
3. Diagnosed by isolating the organism or detection of early-antigen flurescent
foci (DEAFF Technique) from Urine and other body fluid and producing
intracranial calcification. C
By far CMV is the most common maternal infection in UK. It is usually
asymptomatic or has Flu like illness.
4. The organism is teratogenic with sever distinct skin lesions if the mother got
infected during the first trimester while there is a risk of the mothers illness if
she got infected within the week around delivery. H
Varicella in the form of chicken pox or shingles has a tremendous effect on
the devolving embryo during the first half of pregnancy. It produce congenital
varicella syndrome with severe skin scarring and disfigurement beside other
internal organs and eye involvement. Baby will develop neonatal varicella
infection if the mother gets infected 5 days before or two days after the
delivery. Neonatal varicella looks like chicken pos but very serious.
Q. 2 (15 Marks)
This is a list of actions you may ask or do it:
A. Urgent chest X-ray
B. Urgent arterial blood gas
C. Septic screen
D. Blood transfusion
E. Transillumination test
F. Needle insertion in 2nd left intercostals space
G. Coagulation study
H. Call the consultant to come from home
I. Check the Blood pressure
J. Check the endotracheal tube position and patency
K. Abdominal X-ray
L. Intracranial ultrasound
M. Brain MRI
N. Urgent ECG
O. Assess the modified Glasgow coma scale
Choose the most appropriate action for each of the following scenarios:
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Mock Exam Series # 6

Neonatology Test 1

MRCPCH2009 Site
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SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once
1. You are following a preterm baby; 29 weeks on his second day. She is on
moderate setting ventilation being very stable with near normal blood gas.
The reason is respiratory distress syndrome and mother has been given
steroid 2 days before delivery. After you round you went to your room. Two
hours later the nurse has call you to come urgently as the baby is suddenly
desaturated with bradycardia. You came and found the baby in bad
condition. You did your first step assessment and the condition is reversed
immediately after your appropriate action. What is your assessment? J
This is the essential first step you should do if you have sudden deterioration
of previously stable baby on ventilator. Check the tube patency and place,
then the ventilator function and performance. Tube should be replaced
immediately and until preparation ventilate the child with bag and musk.
2. You are following a preterm baby; 29 weeks on his second day. She is on
moderate setting ventilation being very stable with near normal blood gas.
The reason is respiratory distress syndrome and mother has been given
steroid 2 days before delivery. After you round you went to your room. Two
hours later the nurse has call you to come urgently as the baby is suddenly
desaturated with bradycardia. You came and found the baby has limited
chest movement on the right side. You did your essential step of assessment
and it was positive. You call for immediate intervention. What is this step? E
The next essential and emergency step is check for pneumothorax. This can
be done easily and quickly by bedside transillumination test. If it is not ready
or not available insert a needle in the second intercostal space and aspirate
to see if there is any air. Chest X-ray for confirmation and for medico legal
issue but it is not a diagnostic tool in emergency.
3. You are following a preterm baby; 29 weeks on his second day. She is on
moderate setting ventilation being very stable with near normal blood gas.
The reason is respiratory distress syndrome and mother has been given
steroid 2 days before delivery. After you round you went to your room. Two
hours later the nurse has call you to come as the baby is gradually
desaturated and ventilation setting is rising. You came and found the baby
off colored and lethargic. You did your essential step of assessment and
asked for blood transfusion. What is this step? L
If the condition is less urgent Peri-intraventricular hemorrhage should be
ruled out. This can be reliably done by cranial ultrasound in infant with
opened fontanels. Usually high grade will be there, grade III or IV.

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Mock Exam Series # 6

Neonatology Test 1

MRCPCH2009 Site
ELBABA M.A.

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Q. 3 (15 Marks)
This is a list of some medications:
A. Aspirin
B. Warfarin
C. Phenytoin
D. Valproate
E. Carbamazepine
F. Levetiracetam
G. Benzodiazepin
H. Thiouracil
I. Sulphmethoxazol
J. Hydralazin
K. Dipyridamole
L. Thalidomide
M. Haloperidol
N. Methadone
O. Cocaine
P. Lithium
Choose the well recognized teratogenic drug associated with each of the following:
SELECT ONE ANSWER ONLY FOR EACH QUESTION
Note: Each answer may be used more than once
1. Midfacial hypoplasia and neural tube defect D
Sodium Valproate (Depakin) is well known reason for Neural tube defect. High
risk mother in preconception period needs to take prophylactic high doe (5mg
per day)of Folic acid and to change the antiepileptic medication.
2. Limb deficiency; Sirenomelia L
It is an old drug. It introduced for treatment of motion sickness. Limb deficiency,
Phocomilia and Sirenomelia or Mermaid Syndrome are hazardous teratogenity
might occur. Drug is obsolete and removed from the market for long time.
3. Ebstein anomaly P
Lithium therapy (antipsychotic) used in treatment of Manic disorder is
associated with this cardiac anomaly. In Ebstein anomaly there is distal
displacement of tricuspid valve with obliteration of right ventricle and huge right
atrial dilatation.

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Mock Exam Series # 6

Neonatology Test 1

MRCPCH2009 Site
ELBABA M.A.

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BEST OF FIVE QUESTIONS

(5 Marks each)
1. The following may be the reason of neonatal hypertension EXCEPT:
A. 11 hydroxylase deficiency.
B. Middle Aortic syndrome.
C. Previous umbilical artery catheterization.
D. Congenital nephritic syndrome.
E. Maternal Cocaine abuse.
In congenital adrenal hyperplasia, the main difference between 21 & 11
hydroxylase deficiency is the elevation of blood pressure in the later due
to salt and water retention secondary to excess mineralocorticoid as an
alternative pathway after blockage of the main one. Middle aorta that
occurs in William syndrome and other conditions and arterial
catheterization of umbilical artery producing hypertension through their
effect on renal artery by stenosis in the first condition and spasm in the
second one. The most common reason of hypertension in children is
renal in origin in spite of that Congenital nephritic syndrome doesn't
produce hypertension . Cocaine abuse in the mother is associated with
many renal anomalies and hypertension.
2. Maternal Diabetes mellitus affects babies as following : SELECT ONE
A. Macrosomia secondary to passing of high calories through placenta
B. Persistent septal hypertrophic cardiomyopathy
C. Higher incidence and severity of Jaundice due to hemolytic process.
D. Hypermagnesemia secondary to hypocalcemia
E. Higher incidence of Microcolon and caudal regression syndrome
Macrosomia in IDM is due to high production of fetal Insulin and
utilization of high Glucose load. Septal hypertrophy is transient and in
almost all cases will resolve. High incidence of Jaundice is secondary to
Polycythemia. There is Hypomagnesemia as one of the metabolic
complication not hyper. Sacral agenesis (caudal regression syndrome
and microcolon is a recognized association in IDM.
3. All of the following are contraindication to ECMO therapy EXCEPT:
A. Preterm less than 30 weeks
B. Baby weight less than 1 kg
C. Oxygenation index more than 70%
D. Grade IV intraventricular Hemorrhage
E. Platelet count less than 10
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Mock Exam Series # 6

Neonatology Test 1

MRCPCH2009 Site
ELBABA M.A.

____________________________________________________________________________

Extracorporeal membrane oxygenation is the terminal line in treating

respiratory failure. It is very invasive and expensive. There are a certain
criteria to start this kind of therapy because it is available in higher
centers only. The criteria are; Maturity above 35 weeks, weight > 2 kg,
Oxygenation index > 40, reversible lung condition, no underlying cardiac
problem, no coagulation defect or bleeding disorders and lastly, no IVH or
severe brain insult.
4. All of the following
is considered as a risk factor for periintraventricular hemorrhage in preterm EXCEPT:
A. Inappropriate Ventilation setting
B. Patent ductus arteriosus
C. Hypertension
D. Hypotension
E. Maternal use of steroid
All except (E) are underlying risk factors due to vascular instability of the
germinal layer of the cerebral ventricles. On the other hand, one of the
major benefits of RDS prophylactic antenatal maternal use of steroid is
reduce the risk of IVH based on the latest evidences.
5. You have been faced with a flat baby immediately after birth. The baby
is not breathing and heart rate is maintained. You observed a scaphoid
abdomen. Mother was not given Narcotic. What is your first action? :
A. Start suction and free oxygen flow and wait for spontaneous breathing
B. Start bag and musk ventilation
C. Intubate the baby electively and start bag ventilation
D. Intubate the baby and give the chance for spontaneous breathing
E. Try to pass NGT to check for bilateral choanal atresia.
If diaphragmatic hernia is suspected (Not diagnosed) at any time bagging
is contraindicated as it worse the condition more due to inflation of the
bowel in the chest. Now most of cases have been diagnosed antenatally
by ultrasound. But if not, the appropriate action is elective intubation
immediately after birth and passing a NGT to deflate the bowel, keep
NPO and consult the pediatric surgeon. Surgery if preferred to be done
after stabilization of the condition. Outcome depends on the degree of
pulmonary hypoplasia.

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Mock Exam Series # 6

Neonatology Test 1

MRCPCH2009 Site
ELBABA M.A.

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MULTIPLE TRUE/FALSE QUESTIONS

(5 Marks each)
1. You have been called to see a fresh baby with generalized edema and
ascitis. There are no signs of heart failure and investigations revealed
No RH incompatibility. The following may be incriminated as a cause:
A. Finnish nephrotic syndrome
B. Twin to twin transfusion
C. Wolf-Parkinson-White syndrome
D. Congenital Lupus
E. Erythrovirus infection
Causes of non-immune hydrops fetalis is a big list. 15-20% is idiopathic;
the cause is not clear after intensive investigations. It may occur
secondary to heart failure or without heart failure. The middle three
choices in the question are causes of non-immune Hydrops but due to
heart failure which was excluded in the question head. The new name of
Parvovirus B19 is Eryhthrovirus which must be excluded before saying
idiopathic. Finnish type NS is associated with Lager placenta as well.
2. In baby with Hematocrit 0.75. The following complications may occur:
A. Paucity of movement on one side of the body
B. Lip smacking and cycling movement
C. Abdominal distension and bloody diarrhea
D. Hematuria and flank mass
E. Superior vena cava syndrome
All of the above are well recognized complications of polycythemia (By
definition Hct.> 60%). Stroke (A), Seizure (in B) is mainly 2ry to
hypoglycemia or other neurological insults, NEC (C), renal vein
thrombosis (in D) and SVC syndrome (in E) due to obstruction of this
great vein by thrombosis.
3. Which is true concerning hemorrhagic disease of the newborn :
A. It may occur after the third week of life
B. It is due to deficiency of factor II, VII, IX and X
C. Prothrombin and Thrombin time are prolonged
D. UK recommendation in all breast fed babies is oral or IM vitamin K
E. If the baby is symptomatic treatment with oral vitamin K is required.
Typically, it occurs in day 2-6 after birth. Late disease might occur by the
2nd week and up to months after. In the initial simple bleeding is common
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Mock Exam Series # 6

Neonatology Test 1

MRCPCH2009 Site
ELBABA M.A.

____________________________________________________________________________

like umbilical stump but, in the later intracranial hemorrhage is more

common. Only prothrombin T. is prolonged due to lake of vitamin K
associated factors. aPTT might be prolonged as well but not Thrombin T.
which should be normal. Single IM dose or 5 oral Vitamin K doses are
recommended in UK for prophylaxis. The later is better but for possible
uncompliance single IM dose is sometimes preferred. Symptomatic
patient with bleeding should be treated with FFP and IV vitamin K.
4. Non ketotic hypoglycemia in newborn is present in :
A. Persistent hyperinsulinemia hyperglycemia of infancy.
B. Beckwith-Wiedmann syndrome.
C. Infant of diabetic mother
D. Medium chain acyl coenzyme A deficiency
E. Glycogen storage disease type I
Take of spelling! Some tricky words sometimes inserted intentionally.
Persistent Hyperinsulinemia Hypoglycemia of newborn or infancy (PHHN)
NOT hyperglycemia is previously called Neisdioblastosis. Causes of nonketotic are mainly two groups; Hyperinsulinemia or Fatty acid oxidation
defects. A, B and C are related to hyperinsulinemia while D is one of FA
oxidation defect. GSD type I is ketotic.
5. Considering Necrotizing enterocolitis which is or are true? :
A. Pneumatosis intestinalis means stage 3 NEC by Bells staging criteria.
B. Known risk factor in VLBW is early breast feds even in small amount.
C. Serial abdominal X-ray is usually required regardless radiation risk.
D. Polycythemia is one of the underlying risk factor
E. Surgical intervention is limited to perforation or bowel resection.
Bell's stages are three. Pneumatosis intestinalis is stage II while III
involved mainly perforation. Small expressed breast feds are
recommended in preterm not a risk for NEC. It prepares the bowel for
regular feeding later. Serial X-ray is mandatory for follow up and for
possible surgical consultation or intervention at any time. The benefit of it
overweights the risk of radiation. Surgeon has many roles in these cases
not only perforation and resection; it may include peritoneal drain, toilet
and dealing with stricture later on.

End of material

ELBABA 2011
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