0 Not enhance on CECT

Reactions: 


MCQ 112

Which of the following does not enhance or shows minimal enhancement on CECT ?
a. Meningioma
b. Area Postrema
c. Median eminence
d. Cavernous Angioma


ANSWER:
Ans : D





0 Circumventricular organs (CVOs)

Reactions: 


Circumventricular organs (CVOs) are structures in the brain that are characterized by their extensive vasculature and lack of a normal blood brain barrier (BBB).
  1. Area postrema
  2. Organum vasculosum of the lamina terminalis (OVLT)
  3. Subfornical organ (SFO)
  4. Posterior pituitary
  5. Median eminence
  6. Pineal gland



Note:
Inclusion of Choroid Plexus in CVOs is debatable , but it is also outside BBB. Thus enhance on CECT.




0 Normal Cerebral blood volume

Reactions: 

MCQ 111 (All MN FB Page MCQs)

What is the normal range of cerebral blood volume ?

a. 4-5 ml/100g
b. 6-7 ml/100g
c. 40 - 50 ml/100g
d. 50 - 60 ml/100g


ANSWER:
Ans : A
Normal Cerebral blood volume : 4-5 ml/100g
Normal Cerebral blood flow : 50-60 ml/100g/min





0 Arlt

Reactions: 


ARLT

  • "Arlt's line": Linear scar present in sulcus subtarsalis during Chlamydia trachomatis infection.
  • "Arlt's operation": Transplantation of eyelashes back from the edge of the eyelid for treatment of distichiasis.
  • "Arlt's syndrome": A contagious eye infection caused by Chlamydia trachomatis.
  • "Arlt's triangle": keratic precipitates distributed in a wedge-shaped area on the inferior corneal endothelium.





Source : http://en.wikipedia.org/wiki/Carl_Ferdinand_von_Arlt


0 Infant of Diabetic Mother

Reactions: 


Infant of Diabetic Mother


1. Can be Still birth

2. Can be Preterm , IUGR

3. Macrosomia

4. HMD

5. Neonatal Jaundice

6. Hypo Glycemia/Calcemia/Magnesemia

7. Polycythemia - Renal vein thrombosis

8. Lazy left colon syndrome (pseudo-obstruction of intestine - hypoperistaltic)

9. Heart diseases -

  • MC - TGA (also MC congenital anomaly in Infant of diabetic mother)
  • Asymmetrical Septal Hypertrophy
  • Cardiomyopathy
  • Persistent pulmonary HTN

 Important points : 

  • MC congenital anomaly in Still borns of diabetic mother - Neural tube defects
  • MC congenital anomaly in Infants of diabetic mother - TGA
  • Most Specific anomaly in Infants of diabetic mother  - Sacral Agenesis



 Other Points to remember : 


  • MC sign of Acute Hypoxia in Neonates : Bradycardia
  • IOC to look for cerebral perfusion in birth asphyxiated newborn :  ( NIRS ) Near-infrared spectroscopy.
  • Earliest and Most Common organ affected in Birth Asphyxia : Kidneys (ATN-Acute tubular necrosis) , later Brain (HIE - Hypoxic ischemic encephalopathy). 
  • MC cause of Renal failure in Newborn - Birth Asphyxia.




0 Hypocalcemia in Infants

Reactions: 


Hypocalcemia in Infants

Normal Serum Calcium : 9 - 11mg/dl

Hypocalcemia - S. Calcium <7mg/dl ( ionized Ca - <4mg/dl or < 1 mmol/l )

Early Onset ( <72hrs)
Late Onset ( >72hrs)
Cause :
Prematurity
Birth Asphyxia
Infant of diabetic mother

Feeding with phosphate rich milk (cow milk)



100ml Cow milk
Phosphate – 100mg
Calcium – 118mg

Good Ca/Po4 ratio is 2:1

100ml Breast Milk
Phosphate - 15mg
Calcium - 35 mg

Therefore Breast milk is good Calcium supplement and so no late onset hypocalcemia

Cerelac (Docosahexanoic acid , Omega 3 EFA - for brain and eye )
has Ca/Po4 >2


Clinical Features :
  • Tremors
  • Jitteriness (Can be stopped by passive limb restriction)
  • Seizures
  • No Tetany 

Treatment : IV calcium


0 Hypoglycemia in Infants

Reactions: 


Hypoglycemia in Infants

Blood sugar : <40mg/dl

Causes
  1. Inadequate feeding
  2. Inadequate stores (Preterm , IUGR)
  3. Sepsis
  4. Galactosemia
  5. Polycythemia
  6. HyperInsulin (Infant of diabetic mother) 
Pedersen Hypothesis :
In Maternal diabetes - high glucose passes to fetus - Thus fetus' Beta cell undergo hyperplasia and increases Insulin.

Thus tell mother to do frequent feeding and we have to do frequent monitoring.

Treatment :
IV dextrose - Start with glucose infusion 3-5mg/kg/min
or
IM Glucagon (short term measure to tide over hypoglycemia)


Note:
  • Peripheral Vein : till 12.5% glucose can be given. 
  • Central Vein (Umblical vein) : if >12.5% glucose to be given.


0 Medical One Liners 111 - 120

Reactions: 


111. Breast Milk is Contraindicated in Galactosemia

112. If Mother Sputum +ve TB - Still give breast milk to baby ( with 6months course of 5mg/kg INH )

113. Mother with HIV - Never mix feed i.e give exclusive trophic feed or give expressed milk of other women )

114. Mother to Child transmission of HbsAg - Prevent by 
  • HBIG within 12 hr of life
  • Vaccine on day 1 of life.
115. Anti HbsAb Protective Titre - > 10 mIU / ml

116. Liver biopsy in Alpha 1 anti-tripsin deficiency : PAS +ve and Diastase resistant granules

117. CMV : Intranuclear Owl eye inclusion bodies.

118. Nystagmus induced by Valsalva maneuver :

  • Chiari Malformation
  • Perilymph fistula
  • Superior Canal dehiscence syndrome
119. GABA is formed from Pyridoxine.

120. If pregnant lady shows Rubella antibody +ve : It means she is immune to rubella during her pregnancy and need not worry for rubella infection.


0 Cytomegalovirus (CMV)

Reactions: 


Cytomegalovirus (CMV)
  • Periventricular Calcifications
  • Chorioretinitis
  • Convulsions

Asymptomatic CMV is leading cause of Sensoryneural hearing loss ( 7% cases of CMV infection )

Diagnosis : 
CMV is in all body secretions
Thus can be isolated - Urine and Saliva are best specimens for CMV culture

Antigen PP65 - PCR against this is used.
Typical "owl eye" inclusion indicating CMV infection of a lung pneumocyte

Treatment :
IV - Gancyclovir (Side effect - Bone marrow depression)
if resistant - Foscarnet





Image Source : http://en.wikipedia.org/wiki/File:Cytomegalovirus_01.jpg


0 Congenital rubella syndrome

Reactions: 


Congenital rubella syndrome

Triad :
  1. Sensorineural deafness (58% of patients)
  2. Eye abnormalities—especially "Salt-and-pepper" retinopathy, cataract and microphthalmia (43% of patients)
  3. Congenital heart disease—especially patent ductus arteriosus (50% of patients)
Other heart defects :
  • Peripheral pulmonary stenosis
  • VSD
  • ASD is rare
Congenital Cataracts (white pupils) due to congenital rubella syndrome


Other abnormalities to remember :
Microcephaly (Mental Retardation)
















Image Source : http://en.wikipedia.org/wiki/File:Cataracts_due_to_Congenital_Rubella_Syndrome_(CRS)_PHIL_4284_lores.jpg

0 Congenital Syphilis

Reactions: 

Congenital Syphilis

Early ( <2yr )
Late ( >2yr )
  • Mucocutaneous Rash or rhinitis (Snuffles)
  • Similar to Secondary Syphilis in adults

Triad
  1. Hutchinson Teeth (1st lower molors)
  2. Deafness (8th Nerve)
  3. Interstitial Keratitis

  • Lymphadenopahy
  • Autoimmune Haemolytic anemia
  • Osteochondritis and Metaphysitis
  • Glaucoma
  • Pseudoparalysis of parrot (Painful limbs)


  • Saddle Nose
  • Frontal bossing
  • Olympian’s Brow
  • Higoumenakis sign (Prominence of Sternoclavicular joint )
  • Rhagades (rash at shin area)
  • Clutton’s joints




Treatment : Crystalline Penicillin G for 10-14 days


Other causes of Pseudoparalysis of parrot :
  • Scurvey
  • Osteomyelitis
  • Hypokalemia




0 Mother to Child Toxoplasma

Reactions: 



Toxoplasma (protozoa)

Definitive Host : Cat
Incidental host : Human

Prevention : Spiramycin to Mother to prevent vertical transmission to child.

If not prevented :

a. Hydrocephalus
b. Convulsions
c. 24 - 50% cases show Calcifications in
  • Caudate Nucleus
  • Choroid Plexus
  • SubEpendyma

Note : In CMV - Calcifications are Periventricular.





0 TORCH infections

Reactions: 

TORCH infections


Toxoplasma
Others
  • Syphilis
  • HIV
  • Hep B
  • Varicella
Rubella
CMV
Herpes

If Mother gets Rubella after 16wks - Nothing to fetus
But if 10-11 wks - Increased chances of fetal abnormalities

Common points :
1. 50 - 60 % are asymptomatic
2. If symptomatic :
  • IUGR
  • Failure to thrive
  • Anaemia
  • HepatoSpleenomegaly
  • Thrombocytopenia
  • Rash
  • Cholestasis


Infectivity 
1. All of them - at time of delivery.
2. Rubella - 2 peaks -
  • 10-11 wks
  • At time of delivery


If HIV to mother - 
  • Zidovudine after 14 wks pregnancy
  • then For delivery - do elective LSCS
  • If in labor - intrapartum Nevirapine
  • Neverapine to child (oral) x 4-6wks

Diagnosis is based on Serology :

1. IgM - is made by the child itself

2. IgG - is transmitted from mother 
     Considered marker only if :
  • IgG persists 6-9 months
  • or increases in titre


Note : in HIV cases - 
  • No IgM in child
  • IgG persisting >18months is taken as marker. (not 6-9 months)
Thus for 1st 18 months : (as Child of HIV mother will be having +ve ELISA)
  • p24 assay
  • PCR (best but difficult)
  • Viral Culture




1 Cytotoxic vs Vasogenic edema (MCQ)

Reactions: 


Which of the following imaging modality will best differentiate Cytotoxic from Vasogenic edema ?

a. Diffusion Weighted MRI
b. FLAIR sequence
c. Contrast enhanced CT
d. T2 weighted MRI


ANSWER:

Ans : A
Cytotoxic edema shows Restricted Diffusion but Vasogenic edema shows increased diffusion.






0 Neonatal Seizures

Reactions: 


Neonatal Seizures


Most Common cause : HIE ( Hypoxic Ischemic Encephalopathy )

Many neonatal seizures are Metabolic.

Day 1 :
  • Hypo-Glycemia
  • Hypo-Calcemia
  • Hypo-Magnesemia
  • IVH
  • Rarely - Pyridoxine dependent seizures.

Day 3 - 7 :
  • Late Onset sepsis
  • Late Onset Hypo-Calcemia
  • Tetanus Neonatorum
  • Kernicterus

Most Common type : Subte Seizures
  • Vacant Stare
  • Paddling movements
Because : 
  1. Myelination is not completed in NewBorn
  2. Arborization of neurons is not completed

DOC : Phenobarbitone (But 1st check Glucose , Calcium , Magnesium )

Not Diazepam - it has Benzyl Alconium Chloride (preservative) which binds to albumin and displaces bilirubin - therefore can precipitate Kernicterus.


 Pyridoxine dependent seizures : (AR) 

Diagnosis of exclusion

Previously diagnosed by response of IV or Oral Pyridoxine ( Used in India Now also )

Diagnosed Now by : CSF or Plasma - Pyridoxine-5-phosphate.

GABA is formed from Pyridoxine 
Therefore if decreased Pyridoxine - decreased GABA - Therefore decrease Inhibitory stimulus.



0 Neonatal Cholestasis ( Conjugated Jaundice )

Reactions: 


Neonatal Cholestasis ( Conjugated Jaundice )

Direct bilirubin > 2 mg/dl
or
>15 % of Total bilirubin

=> Jaundice + Clay Coloured Stools + Dark yellow urine.

Causes :

1. Medical -
  • MC cause - Neonatal Hepatitis (because of TORCH)
  • Sepsis
  • Galactosemia
  • Alpha 1 Antitripsin deficiency
  • Neonatal Hemochromatosis

2. Surgical -
  • Extra Hepatic biliary atresia (should be operated in 1st 8 wks - Kasai Operation - else 80% die)
  • Gamma glutamyl transferase (GGT) is 10 times higher in surgical



In Biliary Atresia

1. USG : 
  • GB Absent
  • Triangular Cord
2. HIDA scan - IV dye
Not excreted into gut in biliary atresia

3. Gold Standard - PerOperative Cholangiography

MRCP is as good as PerOp Cholangiography


Galacosemia 

Galactose 1-phosphate uridyltransferase is deficient.

Therefore Galactose 1 Phosphate Increase - Hepatotoxic

Triad :
  • Jaundice
  • Hypoglycemia
  • Cataract (because of Galactitol - from Galactose 1 phosphate) 




0 Breast Milk vs Feeding Jaundice

Reactions: 


Breast Milk Jaundice
Breast Feeding Jaundice

Because of pigment in breast milk which inhibits conjugation.
Because of decrease feeding and increased enterohepatic circulation.

At day 14 , approx. 20-30 mg/dl

At around Day 3 of life
Can also occur in next pregnancy


Treatment :
Temporary interruption of breast feeding for
48 – 72 hrs
Ensuring breast milk.





1 Neonatal Jaundice

Reactions: 


Neonatal Jaundice

  • Jaundice is visible in newborn skin when bilirubin > 5 mg/dl
  • Progression - CephaloCaudal

Kramer's Rule/Zones :





Zone    Bilirubin
 1 ----- 5 mg/dl
 2 ----- 10
 3 ----- 12
 4 ----- 15
 5 ----- >15












  • 1g Hb = 34 mg Bilirubin = 1.34 ml O2

  • 1g/dl of Albumin binds 8mg Bilirubin











  • The bilirubin gets conjugated in Liver (via UDP Glucuronyl Transferase).
  • Unconjugated Unbound bilirubin causes Kernicterus.

 Physiological Jaundice of Newborn 

Reasons :
  1. Hematocrit of Newborn is more
  2. Life span of fetal RBC = 90days {Adult is 120}
  3. Y Ligandin - Low
  4. UDP - GT - Low
  5. Excretion - Less
  6. Enterohepatic circulation More

In Term babies - Peaks on day 3 and normal in 7 days (Peak upto 12 mg/dl)

In Pre-term babies - Peaks on Day 5 , normal in 14 days (Peak upto 15mg/dl)

i.e >15mg/dl is Pathological { Palms and Soles - Yellow (see Kramer zones above) }


 Pathological Jaundice 

1. Jaundice on Day 1

2. If
  • Mother Rh - , Child Rh +
  • Cord Blood Hb <10 g %
  • Corl Blood Bilirubin > 5 mg %
  • Direct Coomb's +ve
This is an Indication for Exchange transfusion.

3. if Bilirubin increase rate > 0.5 mg/dl/hr

4. If Jaundice persists
  • >7days in term 
  • >14days in preterm 
5. Jaundice which require therapy.

Most important cause - Rh incompatibility.

Other causes:
  • Minor blood group incompatibility
  • ABO incompatibility
  • Spherocytosis , Elliptocytosis
  • RBC enzyme deficiency - G6PD def , Pyruvate Kinase def.

T/t - 
  • Phototherapy
  • Exchange transfusion


 Phototherapy ( 425 - 475 nm ) - Blue White Light

Water insoluble bilirubin ------> Water Soluble -----> Excreted

Mechanism:
  1. Structural Isomerization (Bilirubin to Lumirubin) (Irreversible)
  2. Photoisomerization
  3. Photo-Oxidation
  • Child 40 cm away from tube.
  • 4 - 6 mg/day fall of bilirubin.

Side effects :
  1. Fever , dehydration ( therefore do frequent feeding or increase IV fluids by 20%)
  2. Retinal Damage (so cover eyes)
  3. Mutations in Gonads (so cover gonads too)
  4. Hypocalcemia
  5. Diarrhoea (watery) - because of bile pigments in gut.
  6. Contraindicated in Conjugated Jaundice (Hepatitis) - else Bronze baby syndrome. 

Persistence / Exaggeration of Physiological Jaundice :
  1. Congenital Hypothyroidism
  2. IVH , Cephalhematoma
  3. Battered baby syndrome
  4. Crigler Najjar Type II / partial deficiency of UDP-GT (Needs life long phototherapy)
  5. Breast Milk Jaundice

Note : In Crigler Najjar Type I - UDP - GT is absent - so all have kernicterus and die.


0 Necrotizing enterocolitis (NEC)

Reactions: 


Necrotizing enterocolitis (NEC)

Necrosis of immature gut.

Risk factors : 
  1. Prematurity
  2. Ischemia to intestinal mucosa because of RDS/HIE/Hypothermia
  3. Artificial feed
  4. Maternal Cocaine


Clinical Features :
  • of Sepsis 
  • Abdominal distention 
  • Blood in stools

BELL'S Staging :

I - Suspected NEC -
  • Abdominal distention
  • Paralytic Ileus
  • Occult blood in stool

II - Definite
  • IIa - Gross blood in stools , Hyponatremia , Metabolic acidosis , Thrombocytopenia.
  • IIb - Pneumatosis Intestinalis (Air in Gut wall)

III - Advanced - Air perforated gut - Shock , Pneumoperitoneum.


Prevention:
Trophic feeds -
Minimal breast milk through NGT (nasogastric tube) {20-30 ml / kg / day}
  • It is for local effect on gut
  • Not for nutrition - for nutrition give IV fluids

Treatment :
  • Stop all oral feeds
  • Put on TPN (Total parenteral nutrition)
  • Ceftriaxone
  • Metronidazole
  • Stage III - May require Surgery -Resection 

Probiotics : Commensals - Prevent NEC ( Not for Treatment )
  • Lactobacillus acidophilus
  • Bifidobacterium infantis
to Very Low birth weight infant.


Also always Think of NEC in infant when :
  • Gas under diaphragm
  • Newborn with Right hypochondrial air in portal tract





0 Medical One Liners 101 - 110

Reactions: 


101. Maple syrup urine disease (MSUD) is caused by a deficiency of the branched-chain alpha-keto acid dehydrogenase complex , leading to a buildup of the branched-chain amino acids (leucine, isoleucine, and valine)

102. The SMA lies to the left of the SMV as it crosses over the third portion of the duodenum. ( Clinical Importance : to check malrotation )

103. Meta-analysis is best for Probiotics' Trial.

104. Vertical crest in fundus of internal auditory canal is - Bill's Bar.

105. Sphincter of oddi has 3 sphincters.

106. Sheath surrounding the neurovascular bundle in axilla is derived from - Prevertebral fascia.

107. 1st part of duodenum has duodenal cap/bulb.

108. Spleen projects into Greater sac.

109. Axillary abscess is drained safely through Floor.

110. The primary direct stimulus for excitation of central chemoreceptors -  H+ increase.




0 X linked Dominant disorders

Reactions: 


X linked Dominant disorders


  • Rett Syndrome (Only seen in female - as it is lethal in males)
  • Urea cycle disorder (OTC deficiency )
  • Familial hypophosphatemic Rickets
  • Incontinentia Pigmenti
  • Alport Syndrome (can be AR and AD also but MC it is X-D)





0 Chromosome 22

Reactions: 


CHROMOSOME 22 :


  • Meningioma
  • Neurofibromatosis 2 ( merlin )
  • Acoustic Neuroma
  • Di George syndrome
  • Velocardiofacial syndrome


Note: 


NF1 - Chromosome 17
NF2 - Chromosome 22






0 Chromosome 21

Reactions: 


CHROMOSOME 21 :
  • Down syndrome (Trisomy) 
  • Amyloidosis 
  • Reduced folate carrier ( SLC19A1 ) ( Folate Transporter ) 
  • Homocystinuria 

Note :


  • Folate Receptor genes (FOLR 1 adult , FOLR 2 fetal , FOLR 3 ) are mapped on Chromosome 11 
  • Reduced folate carrier (SLC19A1) (Folate Transporter) - Chromosome 21.





0 Chromosome 20

Reactions: 


CHROMOSOME 20 :
  • Severe combined immunodeficiencydisease (SCID) - (characterized by a deficiency of the enzyme adenosine deaminase ) 
  • Type 1 MODY 

Note:

  • SCID - Most common form is X-Linked recessive (so k/a - X linked SCID
  • Type 2 MODY - Chromosome 7




0 Chromosome 19

Reactions: 



CHROMOSOME 19 :
  • Myotonia dystrophica
  • Insulin receptor gene
  • NPHS 1 (Nephrin) - Congenital FINNISH type of Nephrotic Syndrome (AR)


Note :
NPHS 1 - Chromosome 19
NPHS 2 - Chromosome 1

Human Insulin gene - Chromosome 11
Insulin Receptor gene - Chromosome 19




0 Chromosome 18

Reactions: 


CHROMOSOME 18 :
  • Edwards syndrome ( Trisomy )( MC syndrome linked to Chromosome 18)
  • de Grouchy Syndrome (distal 18p - ) (2nd MC)
  • Pitt-Hopkins syndrome 
  • Bipolar disorder 





0 Chromosome 17

Reactions: 


CHROMOSOME 17 :

  • p53 gene
  • Neurofibromatosis 1 (neurofibromin gene - NF1 )
  • Medulloblastoma
  • BRCA 1 
  • Canavan disease
  • Small Patella Syndrome.

Note :

BRCA 1 - Chromosome 17
BRCA 2 - Chromosome 13

NF1 - Chromosome 17
NF2 - Chromosome 22




0 Bilateral Choanal Atresia

Reactions: 


Bilateral Choanal Atresia 

{ Newborns are mouth breathers till 4 months. }


  • Therefore Pink when Cries , Blue when feeding.
  • To operate - 1st Do CT scan


if Unilateral - Asymptomatic.




0 Transient tachypnea of the newborn ( TTNB )

Reactions: 


Transient tachypnea of the newborn ( TTNB )


  • Wet Lungs - full of fluid.
  • Resolves in 48-72 hrs


Risk Factors :

  1. LSCS - as the lungs are not squeezed.
  2. Precipitous labor.
  3. Delayed cord clamping.
  4. Macrosomia.
  5. Excessive milking of cord.
  6. Maternal sedation.


Clinical Features :

  • Tachypnoea - resolves in 48-72 hrs.

X-Ray : Prominent horizontal fissure (Most specific and earliest sign)






0 Meconium Aspiration Syndrome (MAS)

Reactions: 


Meconium Aspiration Syndrome (MAS)


- > MC in post term babies , Rare in Preterms.

- > Because of Perinatal hypoxia

  • Glottis open
  • Peristalsis Stimulated
  • Anal Sphincter relax - thus pass Meconium (and as glottis is open - so aspiration)

Meconium effects :

1. Physically - 
  • Block bronchus - thereore cause collapse
  • Ball Valve mechanism - Air leaks - Pneumothorax , Pneumomediastinum.

2. Chemically - irritant

3. Biologically - Good culture medium - therefore risk of sepsis.


Prevention : By Obstetric care

Previously Management (if Meconium stain) - IntraPartum Suction (as head is born) - 1st Mouth , then Nose. {Not done now}

Now Management :

  1. Do TABC ( Thermoneutral environment and ensure Airway, Breathing and Circulation )
  2. Check if Vigorous or Not : if Not - then Do ET suction.


Vigorous baby :
1. Respiratory effort - Good - cry
2. Muscle tone - Good 
3. Heart rate > 100 bpm



0 Retinopathy of prematurity (ROP)

Reactions: 


Retinopathy of prematurity (ROP), previously known as retrolental fibroplasia (RLF)
  • If 100% O2 given to Preterm.
  • Proliferation dilatation and tortuous vessels in Vitreous. 
  • 100% babies are blind.
Severe ROP - tractional retinal detachment.


Stages:
I   - Hypoxic demarcation line
II  - Ridge formation
III - Neovascularization
IV - SubTotal Retinal detachment
V - Total RD

In a preterm - protocol to follow -
  • Look for peripheral retina (Indirect ophthalmoscopy at regular intervals) - Do Cryosurgery if Vascular proliferation.
  • 1st Ophthalmoscopy at 32-34 wks or 4-6wks after birth (preterm baby) , whichever is early.
  • Then at every 2wks , till Retina looks like that of term baby.

ROP + (ROP PLUS ) : Posterior retinal vessels are also involved.


Treatment : Cryotherapy , Laser Photocoagulation , Vit. E therapy.
Severe - may require Retinal Reattachment Surgery.

Risk is HIGH with LBW and ELBW ( <1kg birth weight -> 60-70% have ROP)




0 Total anomalous pulmonary venous connection (TAPVC)

Reactions: 


Total anomalous pulmonary venous connection (TAPVC), is a rare cyanotic congenital heart defect (CHD) in which all four pulmonary veins are malpositioned and make anomalous connections to the systemic venous circulation.
Types :

1. SupraCardiac 

  • Most Common 
  • Pulm. Veins join Superior Vena Cava


2. Cardiac  

  • Pulm. Veins join Coronary sinus


3. InfraCardiac 

  • Pulm. Veins join Portal Vein 
  • Most severe - because of Obstructive pulmonary venous hypertension.
  • Newborn with cyanosis.


All patients have ASD - Very important.
Without ASD there will be pulmonary circuit with no blood for systemic circuit.

MCQ point : O2 Saturation in Pulmonary artery is more than Aorta.

X-Ray features: 
1. SupraCardiac - Snowman Shaped Heart
2. InfraCardiac - Ground Glass appearance with Kerly B lines.




0 Neonatal Pulmonary Alveolar Proteinosis

Reactions: 


Neonatal Pulmonary Alveolar Proteinosis


  • Autosomal Recessive
  • Mutation in gene which coats for Protein B or C or GM-CSF (granulocyte macrophage colony stimulating factor).
  • No response to Surfactant.
  • All will die or Do Lung Transplant.







0 Hyaline Membrane Disease - HMD

Reactions: 


Hyaline Membrane Disease - HMD 

  • Exclusively in Preterm (Never in IUGR baby - as they are in stress so release steroids)
  • > 30% Neonatal Mortality
  • Preterm with respiratory distress.


Normally : Type 2 Pneumocytes produce Pulmonary Surfactant in Alveoli - reduces the surface tension and prevents it from collapsing during expiration.

Surfactant Components :
  • Phosphatidyl Choline
  • Phosphatidyl Glycerol
  • Phosphatidyl ethanolamine
  • Phosphatidyl inositol
  • Protein A,B,C,D

Term Baby with HMD - if Infant of diabetic mother.

Prenatal Diagnosis : L/S ratio in Amniotic fluid. ( Lecithin / Sphingomyelin )
Normally - L/S >2
but in an Infant of Diabetic Mother , Good L/S is > 3.5

Management Prenatal - IM Betamethasone to mother.
Not Dexa - Because it increases risk of PVL (Periventricular Leuckomalacia)

Benefit occurs only after 24hrs to 7days

PostNatal Diagnosis :

1. Shake Test - 
Amniotic fluid or gastric aspirate + Alcohol (equal amount) , shaken for 20 sec.
Then kept in stand for 20 min
  • Term : Layer of bubbles at top of test tube.
  • Preterm : Bubbles Absent

2. X-Ray - Ground Glass Appearance / White out lungs.

Baby <28wks - 60 - 80% have HMD

Treatment - 
1. CPAP - Nasal/PEEP - to keep alveoli distended.
2. Definitive treatment - Surfactant - Prophylactic to preterm , Therapeutic /Rescue
  • Route : IntraTracheal
  • Most commonly used - Survanta (Bovine)
  • Others - Curosurf (Porcine) , Infasurf ( Calf )




0 Respiratory Distress in Newborn

Reactions: 


 Respiratory Distress in Newborn 

1. Tachypnoea - >60

2. Respiratory distress - Tachypnoea + Increase work of breathing
                                                            - Dilation of Ala Nasi
                                                            - Intercostal & Subcostal retractions
                                                            - Grunting

 Causes  

1. Preterm : HMD (=RDS) - Most Common in preterm

2. Term : 
  • TTNB (Transient tachypnoea of newborn)
  • MAS (Meconium aspiration syndrome)

3. Congenital : Diaphragmatic Hernia , Tracheo-oesophageal fistula


Diaphragmatic hernia - (Surgical Emergency)
  • Scaphoid Abdomen
  • Barrel shaped chest
  • Mediastinal shift to right (in Bochdalek)
  • Apparent Dextrocardia (in Bochdalek)
  • Peristaltic sounds on left side (in Bochdalek)


Develops from ( for a related MCQ - Click here )
a. Septum transversum
b. Pleuroperitoneal Membrane
c. Dorsal Oesophageal mesentry
d. Body wall
e. Cervical Myotome

Types : Read More
  • Bochdalek (90% cases) - Left Posterior ( Mnemonic : BPL ) 
  • Morgagni - Right Anterior ( Mnemonic : ARM)

There is Pulmonary hypoplasia due to this and it causes distress.

Bag and Mask ventilation is Contraindicated in diaph. hernia.
Because some air goes to stomach and distends it - thus press diaph. even more.

So Intubate.


Tracheo-oesophageal Fistula : Not Emergency

MC - Upper end blind and lower end communicate with trachea.
Sign - Nasogastric tube coils in upper end of oesophagus.
  • Dribbling saliva from mouth
  • Aspiration of gastric juice (Aspiration Pneumonia - This is Emergency)

Do Continuous Suction and prop the child up.





Medical Notes , Medical MCQs , Medical Mnemonics , Medical Most Common , Medical One Liners. The Online medical study zone. Making medical study easy.

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MedicoNotebook

Medical Notes , Medical MCQs , Medical Mnemonics , Medical Most Common , Medical One Liners.
The Online medical study zone. 

Making medical study easy.






0 Neonatal Sepsis

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Neonatal Sepsis :

Clinical features of Sepsis and bacteremia.

  1. Lethargic
  2. Feeding difficulty
  3. Seizures


Early ( <72hrs )

Late ( >72 hrs )

Pneumonia more common
Septecemia , Meningitis is common , Pneumonia.
Therefore LP is done
Maternal Risk factors
Maternal fever <2wks
Maternal foul smelling liquor
Premature rupture of membrane
Maternal Pain abdomen
Chorioamnitis
Multiple Vaginal examinations in mother
Nosocomial
Organisms : E.Coli , Group B Sterptococcus

Klebsiella , Listeria , E.Coli
Treatment : Ampicillin + Gentamycin
3rd Generation cephalosporins
Cefotaxime + Amikacin


Overall MC organism - Klebsiella
2nd MC - Staphylococcus Aureus

Sepsis Screen for early diagnosis :
1. TLC : < 5000 /cumm (More Suggestive)
              > 5000 /cumm

2. Absolute Neutrophil count : <1500 / cumm

3. Peripheral Smear for band cells (immature neutrophil) & toxic granules : >20% of total neutrophils

  • Thus I / T : >0.2 (Immature / Total Neutrophil )


4. Micro ESR : >15 mm fall in 1st hour

5. CRP : +ve

6. LP : in Late onset sepsis

7. CxR

Antibiotics Course duration
Bacteremia : 10-14 days
Meningitis : 3wks
Arthritis ; Osteomyelitis : 4-6wks




0 Hypothermia in Newborn

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Hypothermia in Newborn :

Grading based on Core Temperature (i.e temperature of Middle ear or Oesophagus)
Normal Core body temp. - 36.5 - 37.5 degree C
Rectal Temperature is close to it.

36 - 36.5 -- Cold Stress (Abdomen warm , Soles Cold ) -- Do Kangaroo Mother Tech.
32 - 36 ---- Moderate Hypothermia
< 32 ------- Severe Hypothermia

In Hypothermia < 36 - Admit NICU

Normal Baby - Abdomen Warm , Sole Warm and Pink.


All Newborns have NON-Shivering Thermogenesis -- Brown fat

Brown Fat - ( Fatty Acid Oxidation - Generate heat - distributed by Blood Vessels)
  • Nape of Neck
  • InterScapular area
  • Around Kidneys and adrenals


Q. Mechanism of Heat transfer in Over head Radiant Warmer ?

ANSWER:
Ans : Convection





0 Normal Neonatal Phenomenons

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Normal Neonatal Phenomenons

1. Milia - (distended sebaceous glands) white spots on face , nose

2. Erythema Toxicum - (day 2 - 3 life ) erythematous macules on face and trunk

3. Stork Bites - (Capillary Hemangiomas) Pinkish greyish

4. Epstein pearl - (epithelial inclusion cyst) - Palat and perpuce , white spots

5. Natal teeth - (predeciduous teeth - lower incisor position)

  • if interfere in feeding - remove them
  • are loose therefore risk of aspiration
6. Withdrawal vaginal bleed - (on 5 - 7 day) Because of withdrawal of maternal hormones.

7. All newborns loose weight 
  • Term - can loose 10% Birth weight and regain BW by 7-10 days
  • PreTerm - can loose 15% , take 2wks to regain
No Phase of Weight Loss in IUGR babies.





0 Neonatal Reflexes

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1. Moro Reflex 

(A response to a sudden loss of support, when the infant feels as if it is falling.)
  • Appears - 28 - 32 wks
  • Fully developed - 37 wks
  • Disappear at around 3 months
  • Abnormal If persists >6months

1st Phase
Abduction at shoulder , Extension at elbow , Opening of fingers

2nd Phase (37 wks)
Adduction at shoulder , Flexion at elbow

Prolonged in Cerebral Palsy

Exaggerated in Birth asphyxia

Asymmetric in- 
a. # humerus , clavicles
b. Erb's Palsy
c. Spastic hemiplegia


2. Grasp Reflex 
Followed by Shoulder traction

Onset - 28 wks
Fully developed - 32 wks
Disappear at 12wks(3months) of age.


3. Sucking and Rooting reflex 

Appear at 32wks
Co-ordinated at 34 wks

Therefore child >34 wks or >1.8 Kg Birth weight can breastfeed.

<32 wks -> Nasogastric expressed breast milk
32 - 34 wks -> Catori , spoon , Paladay


4. Asymmetric Tonic Neck Reflex (ATNR) 

Occiput side - flexed
Side facing - extended

Appears - 35 wks
Fully developed - 1 month life

Stays for 6-7 months

Thus rolling of child - approx. 6 months (when ATNR disappears)


5. Symmetrical TNR 

If extend head of a newborn -
Tone increases in UL and decreases in LL

If Flex head of newborn
Tone decrease in all 4 limbs

It is the Most difficult Neonatal reflex to elicit

Disappears at 6-7 months





0 Apnea at birth

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Apnea at birth :

Causes : MC cause in Preterm is MIXED

Central
Obstructive

Preterm babies
(Normally - All Newborns are Nose breathers till 4 months.)
Asphyxia
Secretions in Nose
Sepsis
Preterm
Hypoglycemia




Apnea of Prematurity (rare cause of Apnea) :

<28 wks --> 100% have apnea
28-34 wks --> 25%

Onset - Usually 1st 2 days of life (Never after 1st week of life)

T/t -
  1. CPAP
  2. MethylXanthines (Theophyline , Aminophyline)
  3. Caffeine Citrate (DOC for Apnea of Prematurity)


Aminophyline :
Used in
  1. Status asthamaticus
  2. Apnea of Prematurity
Loading Dose        : 5 - 6 mg/kg
Maintenance dose  : 1-2 mg/kg (every 6-8 hrs)



0 Contraindications of Indomethacin

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Q. Contraindications of Indomethacin include all except ?

a. Large IVH
b. Renal Failure
c. Hepatic Failure
d. NEC


ANSWER:

Ans : A (Large IVH)

C/I of Indomethacin are:

  1. Renal Failure
  2. Hepatic Failure
  3. DIC
  4. NEC





0 Complications of Preterm

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Complications of Preterm

  • 1. HMD (Hyaline membrane disease) = RDS Respiratory Distress syndrome (>30% of neonatal mortality) 
  • 2. Apnea ( >20sec , or Any period if associated with central cyanosis and bradycardia )
  • 3. Chronic lung disease (= Bronchopulmonary dysplasia) - Oxygen dependence even after >4wks life - Therefore give Home O2 Therapy.
  • 4. CNS Depression (Birth asphyxia) , IVH (Intraventricular haemorrhage) , PVL (Periventricular Leucomalacia) 

IVH - because capillaries in germinal matrix are fragile
  1. Sudden death , 
  2. Sudden shock , 
  3. Bulging out Anterior fontanale (Therefore do Transfontanale USG)
  4. Seizure
(Note : Term babies IVH - because of breech presentation.)

Birth Asphyxia
In Preterm - PVL --> Commando Crawling (UL strong , LL weak) -- Spastic Diplegia --> Cerebral Palsy


In Term - Parasagital --> Prolonged asphyxia --> Diffuse neuronal loss --> Status Marmoratus --> When child grows -- Spastic Quadriplegia --> Cerebral palsy

Cerebral Palsy Complications :
  1. Global developmental delay
  2. Microcephaly & Mental Retardation
  3. Seizures
  4. Feeding difficulties


  • 5. CVS - Hypotension , PDA ( because of prostaglandins due to asphyxia ) (Treatment of PDA here - NSAIDS -  Brufen , Indomethacin )

      Brufen is preferred over Indomethacin because of less renal side effects , i.e both decrease GFR but its less with brufen.

    In Term - PDA is usually due to Rubella - because of vessel wall defect (therefore here t/t - Surgery - Inserting coils in Ductus Arteriosus or Use Duct Occluders.)

  • 6. Blood - Anaemia , Jaundice of Prematurity
  • 7. Hypothermia , Hypoglycemia , Hypocalcemia
  • 8. Gut - NEC
  • 9. Infections (because of decreased immunity)
  • 10. ROP (Retinopathy of prematurity = Retrolental fibroplasia - if 100% oxygen given) - Proliferated, dilated and tortuous vessels in Vitreous.




0 IUGR Types

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 Intra Uterine Growth Retardation Types :

Symmetrical
 MC in west
Asymmetrical
MC in India
Cause : Chromosome Abnormality

Maternal Complication
  1. Decreased Cell Number
  2. Cell size decreased/normal
  3. Brain size decreased

  1. Cell number Normal
  2. Cell size decreased
  3. Head size normal (Head Sparing = Brain sparing)

Therefore HC > CC by >3cm

Ponderal Index (PI) =
{ Weight (g) / Length3 (cm) } x 100

Here PI > 2 (also in Normal babies)



PI < 2




Normal HC/AC

  • is >1 -at-- 32wks
  • is =1 -at-- 32-34 wks
  • is <1 -at-- >34wks
But in asymmetrical IUGR -- HC / AC remains High (because HC is spared)


Normal FL/AC is aprrox = 22 after 21 wks till term.
In asymmetrical IUGR it increases >23.5 as FL is not affected in asymmetrical IUGR






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