Diseases and Injuries of the Fetus and Newborn

DISEASES AND INJURIES OF THE FETUS AND NEWBORNOrpha Montillano-Corrado, MD

I. Diseases Common In The Preterm Fetus And NewbornII. Diseases Of The TermIII. Injuries Or The Fetus And Newborn

DISEASES COMMON IN THE PRETERM FETUS AND NEWBORN

RESPIRATORY DISTRESS SYNDROME (Hyaline membrane disease) can develop in term newborns with sepsis and meconium aspiration Clinical Findings:

Tachypnea Chest wall retractions Expiration with grunting and nasal flaring

Pathology If surfactant is inadequate, hyaline membranes form in the distal

bronchioles and alveoli, Low pressures cause collapse at end expiration

Respiratory insufficiency can be caused by sepsis, pneumonia, meconium aspiration, pneumothorax, heart failure malformations involving thoracic structures

Inadequate surfactant with subsequent lung collapse Unstable alveoli---low pressure cause collapse at end expiration Immaturity of the chest wall

Diagnosis Arterial blood gases Chest radiograph

Air bronchogram Ground glass appearance Lung opacity

Treatment Excess oxygen can damage the pulmonary epithelium and the retina1) CPAP(continuous positive airway pressure)

Prevents collapse of unstable alveoli and allows high inspired O2 concentration to be reduced

2) SURFACTANT-prevents development of HMD Antenatal corticosteroids and surfactant dec death rate

3) Correction of acidosis and antibiotics GLUCOCORTICOIDS

Prevents chronic lung disease but not recommended due to limited benefits and adverse neuropsychological effects.

Complications1) Bronchopulmonary dysplasia-persistent hyperoxia

Cases seen before 30 wks (Baraldi and Filippone, 2007)2) Pulmonary hypertension3) Retinopathy of prematurity (Retrolental Fibroplasia)

Prevention ANTENATAL CORTICOSTEROIDS

Decreases respiratory distress and Intraventricular hemorrhage in infants born between 24-34 wks.

INTRAVENTRICULAR HEMORRHAGE Also called IVH, is bleeding into the ventricles of the brain Prematurity is the greatest cause of intraventricular hemorrhage, and most

cases of IVH occur in babies less than 30 weeks gestation or under 1,500 grams (3 lbs 5 oz).

Four categoriesI. Subdural Hemorrhage

Result of trauma Minimal neurologic abnormalities

II. Subarachnoid III. Intracerebellar IV. Periventricular-Intraventricular

Hemorrhage results from either asphyxia or trauma PERIVENTRICULAR-INTRAVENTRICULAR

Bleeding extends to the ventricular system and brain parenchyma Hemorrhages develops within 72 hrs after birth and large lesions can

result to hydrocephalus and periventricular leukomalacia INTRAVENTRICULAR HEMORRAGE

In preterm neonate pathogenesis is multifactorial which includes1) Hypoxic-ischemic events2) Anatomical factors3) Coagulopathy

Bleeding into the parenchyma causes serious damage

Most hemorrhages are silent and small germinal matrix hemorrhages are confined to cerebral ventricles resolved without impairment

Pathology Damage to the germinal matrix capillary causing extravasation of bld into

the surrounding tissue. In preterm -fragile tissue due to:

1) Subependymal germinal matrix provides poor support2) Venous anatomy causes stasis and congestion3) Vascular autoregulation is impaired before 32 wks

Incidence Depends on the gestational age) Half of the neonates born before 34 wks will have some evidence of

hemorrhage (Hayden and associates 1985)

BRAIN DISORDERS 1) Neonatal Encephalopathy2) Cerebral Palsy Perinatal Asphyxia

Hypoxic-ischemic encephalopathy Characterized by clinical and laboratory evidence of acute or subacute

brain injury due to asphyxia. The primary causes of this condition are systemic hypoxemia and/or reduced cerebral blood flow

Diagnosis Guidelines from the American Academy of Pediatrics (AAP) and the

American College of Obstetrics and Gynecology (ACOG) for hypoxic-ischemic encephalopathy must be present for the designation of perinatal asphyxia severe enough to result in acute neurologic injury:

Profound metabolic or mixed acidemia (pH < 7) in an umbilical artery blood sample, if obtained

Persistence of an Apgar score of 0-3 for longer than 5 minutes Neonatal neurologic sequelae (eg, seizures, coma, hypotonia) Multiple

organ involvement (eg, kidney, lungs, liver, heart, intestines) Management

Following initial resuscitation and stabilization, treatment is largely supportive and should focus on the following1) Adequate ventilation2) Perfusion and blood pressure management -3) Careful fluid management4) Avoidance of hypoglycemia and hyperglycemia5) Hyperthermia management 6) Treatment of seizures

Hypothermia Therapy Extensive experimental data suggest that mild hypothermia (3-4°C

below baseline temperature) applied no later than 6 hours following injury is neuroprotective.

CEREBRAL PALSY Is an abnormality of motor function (as opposed to mental function) and postural

tone that are cerebral in origin acquired at an early age, even before birth. Signs and symptoms of cerebral palsy usually show in the first year of life.

The predominant symptoms and signs of cerebral palsy are related to motor difficulties ….such as developmental motor delay, gait disorders, poor fine and gross

motor coordination, swallowing disorders, or speech delay are all the result of the basic motor disorder

By: Rem Alfelor Page 1 of 4

Trauma term/Hypoxia in preterm


This abnormality in the motor system is the result of brain lesions that are non-progressive.

One-time brain injury, that will not occur again. Classified by the type of neurological dysfunction

1) Spastic Cerebral Palsy Strong association\ with mental retardation and seizure disorder-

20% Result from interruption of blood supply prior to delivery

2) Dyskinetic Cerebral Palsy According to the predominant symptoms dyskinetic CP may be

either Dystonic or Choreoathetotic includes ataxic cerebral palsy

Usually has genetic in origin3) Hypotonic Cerebral Palsy

Based on limb distribution involvement1) Quadriplegia2) Diplegia

Common in preterm and low birthweight- 30%3) Hemiplegia- 30%4) Monoplegia

Prenatal causes-70% Metabolic (severe hypoglycemia), TORCH, brain malformation or infracts,

toxins, genetic syndromes, rhesus incompatibility Natal causes-10% Postnatal causes- 20%

Meningitis, Traumatic Brain Injury, Toxins

FETAL TO MATERNAL HEMORRHAGE 2 most important blood group system

ABO Group Rhesus Group



Maternal antibodies cross the placenta and attached to the fetal RBC leading to RBC destruction

Sequestration of macrophages in the fetal spleen (extravascular hemolysis) produces FETAL ANEMIA

If a mother has been sensitized before , there is a risk of the Rhesus + fetus developing hemolytic anemia and in severe cases HYDOPS FETALIS

HYDROPS FETALIS is an excess accumulation of fluid in the fetus Edema of fetus and placenta, ascites, pleural effusions and/or pericardial

effusions. Most cases of hydrops were caused by severe erythroblastosis fetalis secondary

to Rh isoimmunization

D-negative nonsensitized mother One dose of Anti-D immunoglobulin given at 28 wks Second dose given after delivery if the baby is D-positive.

ABO INCOMPATIBILITY Common cause of hemolytic dse of the newborn 20% of fetus has abo maternal bld gp incompatibility

1) ABO dse frequently seen in first born2) Most species of anti-A and anti-B are Immunoglobulin (IgM) which does

not cross the placenta, does not reach fetal erythrocytes3) Milder than D-isoimmunization , rarely results in anemia4) Can affect future pregnancy but rarely becomes progressively more

severe Treatment

Phototherapy Exchanged transfusion with o negative blood

Diseases Of The Term Fetus And NeonateI. RESPIRATORY DISTRESS SYNDROME

II. MECONIUM ASIII. PIRATION SYNDROMEHEMORRHAGIC DISEASE OF THE NEWBORNIV. FETAL DEATH

RESPIRATORY DISTRESS SYNDROME in term infants Sepsis, group B strep, intrauterine acquired pneumonia, pulmonary hpf,

meconium aspiration and pulmonary hemorrhage

MECONIUM ASPIRATION Peripartum inhalation of meconium stained fluid –chemical pneumonitis,

mechanical airway obstruction, hypoxia

HEMORRHAGIC DISEASE of the newborn Spontaneous internal and external bleeding beginning anytime after birth



Results from abn low vit k dependent clotting factors (V,VII, IX, X ,prothrombin , protein C and S

Early Bleeding 48 hrs after birth Develops in infant not treated with vit k

Late Bleeding 2- 12 wks after birth to infants exclusively breastfeeding

(breast milk has low levels of vit k) Other causes:

Hemophilia, congenital syphilis, sepsis, thrombocytopenia erythroblastosis and intracranial hemorhage

Prophylaxis Vit k 1mg IM at delivery Active bleeing vit k is given IV Oral adminitration is not effective

INJURIES OF THE FETUS AND NEWBORNI. Head injuriesII. Nerve InjuriesIII. Skeletal and muscle injuriesIV. Congenital injuries

HEAD INJURY1) INTRACRANIAL INJURY

Spontaneous Subarachnoid/subdural bleeding is the most common type (doesn’t

result from a traumatic delivery) Traumatic Treatment:

Minimal handling Management of ICP Thermoregulation, o2 and ventilatory support Vit k for coagulation defect

CAPUT SUCCEDANEUM Effusion overlies the periosteum and consist of edema fluid

CEPHAL HEMATOMA Lies under the periosteum and consist of blood

NERVE INJURYI. SPINAL INJURY

Excessive traction during delivery, fracture or dislocation of the vertebrae Seen usually in forceps or breech delivery

II. BRACHIAL PLEXOPATHYIII. FACIAL PARALYSIS

BRACHIAL PLEXOPATHY1) ERB-DUCHENNE PARALYSIS

Damage to the upper plexus Injury to the 5-6th cervical root Absent Moro on the affected side Paralysis of the deltoid, infraspinous muscle

2) KLUMPKE’S PARALYSIS Damage of the lower plexus Injury to the 7th and 8th thoracic root Loss of sensory and motor function to the hand and wrist

FACIAL PARALYSIS Pressure on the facial nerve (7t h nerve) as it emerges from the stylomastoid

foramen 20% associated with forceps delivery

CONGENITAL INJURIES Amnionic band syndrome- strip of band form a focal ring around an extremity or

digit producing constriction to cause damage

SKELETAL AND MUSCLE INJURIES Clavicular Fracture-common

Incidence is 3-18/ 1000 live births Humeral Fracture- uncommon Femoral Fracture

Rare Associated with breech delivery

Skull Fracture 75% instrumental delivery When head is deep in the pelvis

Sternocleidomastoid Muscle- injured (breech delivery)


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Diseases and Injuries of the Fetus and Newborn