COMMON PROBLEMS IN THE NEWBORN

OUTLINE

Different birth injuries a neonate can incur Different causes of sepsis and its treatment

BIRTH INJURIES or BIRTH TRAUMA

refers to avoidable and unavoidable injury affecting the infant during labor and delivery

Injury:MechanicalHypoxic ischemic

BIRTH INJURIES or BIRTH TRAUMA

due to tremendous pressure incurred while passing through the birth canal

BIRTH INJURIES Most often not serious Temporary loss of nerve or

muscular function caused by bruising, pressure or swelling around the nerves can similarly resolve itself within weeks or months.

However, if the nerves are torn, the resulting damage may be permanent.

RISK FACTORS:

Macrosomia Prematurity Cephalopelvic disproportion Dystocia Prolonged labor Abnormal fetal presentation doctor procedures (i.e., the use of forceps)

COMMON BIRTH INJURIES

Caput Succedaneum. Cephalhematoma Bruising / forceps marks Subconjunctival hemorrhage Fractures Facial paralysis Brachial palsy

Soft tissue injury:

1. Erythema and abrasion

2. Petechiae

3. Ecchymosis

4. Laceration

5. Subcutaneous fat necrosis

Erythema and abrasion

Frequently occurs with labor dystocia or forceps delivery

Resolve spontaneously Rx: clean area and avoid secondary

contamination

Petechiae

Commonly occurs with breech or difficult delivery

Due to sudden intrathoracic and venous pressures during chest passage

Commonly found in neck, face, upper chest Resolve in 2-3 days Make sure underlying hemorrhagic disorders

are ruled out

To rule out underlying hemorrhagic disorders:

Birth history Early appearance of petechiae which does

not increase in number Localized petechiae distribution in face and

chest No bleeding from other sites Normal platelet count

Ecchymoses

Occurs in traumatic birth or breech Increase incidence in premature babies Resolve spontaneously within 1 week Complication: hyperbilirubinemia

Laceration

Due to scalpel injury during CS Sites; buttocks, scalp, thigh (presenting part) Rapid healing If superficial: adhesives If deep: sutures used

Subcutaneous fat necrosis Unknown etiology Well-circumscribed indurated lesion in skin and tissues Factors:

OB trauma Local ischemia Hypothermia Intrauterine asphyxia

Lesions appear 6-10 days of age Overlying skin is red or purple with local tenderness or warmth Rx: observe Takes weeks to months

HEAD INJURIES

Caput succedaneum

Vaguely demarcated area of edema over portion of scalp that was presenting part

External to periosteum Cross suture lines Resolve

spontaneously within days

Cephalhematoma

Collection of blood in subperiosteum

Due to rupture of blood vessels traversing from skull to periosteum

No extension over suture lines

Parietal bones – most commonly involved

Complications: jaundice, skull fracture, intracranial hemorrhage

Cephalhematoma

common among neonates delivered by vacuum extraction

Spontaneous resorption in 2-8 weeks

CEPHALHEMATOMA ASPIRATION is contraindicated

Delivery through Vacuum Extraction (ventouse)

CAPUT SUCCEDANEUM CEPHALHEMATOMA

Subgaleal hemorrhage

most feared complication of Vacuum extraction and forceps delivery

potentially life threatening

Subgaleal hemorrhage caused by rupture of the emissary veins, which are

connections between the dural sinuses and the scalp veins.

Blood accumulates between the epicranial aponeurosis of the scalp and the periosteum. This potential space extends forward to the orbital margins, backward to the nuchal ridge and laterally to the temporal fascia.

In term babies, this subaponeurotic space may hold as much as 260 mL of blood.

Subgaleal hemorrhage can therefore lead to severe hypovolemia

Clinical findings: Generalized scalp

swelling and laxity scalp

Ballotable mass that extends beyond scalp sutures

May extend from orbit to ears and down the neck

Occurs insiduously

Subconjunctival hemorrhage Bright red patches on

bulbar conjuctivae very common for

babies born vaginally The redness is usually

absorbed in a week to ten days.

FRACTURES

Most common fracture: Fracture of the clavicle

The clavicle may break when there is difficulty delivering the baby's shoulder or during a breech delivery.

Parents are advised not to lie the infant on the affected side until the fracture has healed.

CLAVICLE

It is particularly vulnerable when there is:

1. Difficulty in delivery

of the shoulder in

vertex presentations

2. The extended arms in

breech deliveryries.

Fracture Humerus most common long bone

fracture Almost invariably heal with simple supportive

therapy & do not lead to permanent disability

SKULL FRACTURES

Uncommon in newborns Skull bones are less

mineralized Bones are separated

by membranous sutures

Usually follows forceps delivery

SKULL FRACTURES

types:

1. linear fracture - no Rx required

2. depressed fractures: Rx- surgical

* elevate severe depressions to prevent cortical injury from sustained pressure

Intracranial hemorrhage

Periventricular Intraventricular hemorrhage Most serious Major cause of death in

prematures Incidence increases with

decreasing body weight and gestational age

Subdural hemorrhage Very rare Seen more in FT

infants Secondary to

precipitous delivery, high or midforceps delivery

Dx: CT scan / MRI

Peripheral Nerve Injuries

PERIPHERAL NERVE INJURIES

Results from excessive tension on one side of the neck

BRACHIAL PALSY PHRENIC NERVE

PARALYSIS FACIAL NERVE PALSY

Brachial Plexus Palsy:It is due to over traction

on the neck as in:

1. Shoulder dystocia.     

2. After-coming head in breech delivery.

BRACHIAL PLEXUS INJURY

Forms:

1. Erb-Duchenne paralysis

2. Klumpke’s paralysis

ERB-DUCHENNE PARALYSIS

Upper arm paralysis Injury to C5 and C6 Most common classical ‘waiter’s tip’

posture

ERB-DUCHENNE PARALYSIS

the arm hangs by the side and is rotated medially; the forearm is extended and pronated.

The arm cannot be raised from the side;

The Moro reflex is absent on the involved side, and the hand grasp is intact

Good prognosis

Klumpke paralysis Rare Lower arm paralysis Injury to C7 and C8 and

T1 (paralyzed hand) a characteristic sign is the

claw hand, due to loss of function of the ulnar nerve and the intrinsic muscles of the hand it supplies

Klumpke paralysis Hands are paralyzed,

grasp reflex is absent if the sympathetic

nerves are injured, an ipsilateral Horner syndrome (ptosis, miosis, enophthalmos)

Poor prognosis

PHRENIC NERVE PARALYSIS

Injury to C3, C4 and C5 may lead to diaphragmatic paralysis and

respiratory distress In difficult breech deliveries s/s: poor respiratory effort

breath sounds absent on affected side Treatment: supportive

FACIAL PARALYSIS

During labor or birth, pressure on a baby's face may cause the facial nerve to be injured.

This may also occur with the use of forceps for delivery.

Mosby items and derived items © 2006, 2002 by Mosby, Inc.

Facial Paralysis 15 Minutes after Forceps BirthFacial Paralysis 15 Minutes after Forceps BirthAbsence of movement on affected side is especially noticeable when infant criesAbsence of movement on affected side is especially noticeable when infant cries

CENTRAL PARALYSIS PERIPHERAL PARALYSIS

Spastic Flaccid

Lower half to 2/3 of face Entire ½ of face

Contralateral side Ipsilateral side

Affected side is smooth Eyes persistently open

Nasolabial fold is obliterated Nasolabial fold obliterated

Mouth corner droops Mouth corner droops

Forehead and eyelid unaffected Forehead and eyelid affected

Complete agenesis of the facial nucleus results in a central facial paralysis; when this is bilateral, as in Möbius syndrome, the face appears expressionless.

Hypoplasia of the depressor anguli oris muscle

Should not be confused with facial palsy

Asymmetric crying facies No treatment is required

for this defect, but a thorough physical examination is warranted for all neonates to look for other malformations.

SCIATIC NERVE INJURY Causes:

1. Breech deliveries with traction on the presenting leg

2. may follow IM injection

3. May follow umbilical artery catheterization s/s: foot drop, adductor paralysis and

sensory loss with intact urinary and rectal sphincters

SPINAL CORD INJURIES Usually happens when there

is difficulty in the delivery of the shoulder in head presentations and the head in breech presentations

If complete transection: permanent paralysis of the parts below the level of injury

If paralysis due to compression by edema and hemorrhage: partial or complete recovery

PROGNOSIS: For those with severe

spinal cord injuries, they die in the early neonatal period

INTRA-ABDOMINAL INJURIES

Uncommon Should be suspected in NB with pallor, irritability

and abnormal distention without evidence of external blood loss

Liver- most frequently injured abdominal organ in traumatic birth process

Mass maybe palpable in the RUQ and abdomen may appear blue

Also possible but rare: spleen rupture, adrenal hemorrhage, kidney injuries

NEONATAL SEPSIS

Neonatal sepsis

Clinical syndrome of bacteremia characterized by s/s of infection in the first 4 weeks of life

CLASSIFICATION OF NEONATAL SEPSIS

EARLY ONSET LATE ONSET VERY LATE ONSET

Time of onset Birth-7 days (usually <72 hrs)

7 days -30 days >30 days

Maternal OB complications

Often present Usually absent Varies

Transmission/ organism source

Vertical: maternal genital tract

Vertical or postnatal environment

Environment/community

Clinical manifestation

Fulminant course; multisystem involvement, pneumonia common

Insiduous, focal infection, meningitis common

Multisystem or focal

RSK FACTORS for SEPSIS

EARLY ONSET LATE ONSET

PrematurityLBWPROMMaternal feverChorioamnionitisMaternal UTIFunctional deficiencies of neonatal host defense mechanisms

PrematurityProlonged hospitalizationInvasive procedures: umbilical catheterizations, ET intubationParenteral alimentationPrior use of antibioticsMedications (H2 blockers)Functional deficiencies of host defense mechanisms

PREMATURITY – most important factor predisposing to infection Usually have a 3 to 10 fold higher incidence of

infection than FT infants

Why are NB prone to sepsis?

NB specific immune mechanism is competent BUT antigenically inexperienced and functionally deficient Antibody responses to infection are poor Complement levels are low Decreased ability of the granulocytes and

phagocytes to kill bacteria Deficient neutrophil chemotactic response

TRANSMISSION of Infection

1. Transplacental- CMV & Rubella

- Listeria Monocytogenes ( the only bacteria)

- Treponema pallidum

2. Vertical- Ascending route ff rupture of membranes

- Passage through birth canal by colonization of normal flora by mother (GBS, E coli)

3. Postnatal- direct contact with caregiver

- environmental/contaminated equipment

Predominant pathogens for Sepsis:

EARLY ONSET(usually normal flora of

genital tract and rectum)

LATE ONSET

E coliGroup B StrepL monocytogenesH influenzaEnterobacter aeruginosaKlebsiella pneumoniaeStaph aureus

Coagulase negative StaphStaph aureusGram negative enteric bacilliPseudomonas aeruginosaEnterococcus speciesFungal

Clinical signs of sepsis:

Respiratory distress Abnormal skin perfusion Temperature instability Feeding intolerance Abnormal HR and BP Metabolic problems – hypo/hyperglycemia,

metabolic acidosis Abnormal neurologic status

Neonatal Sepsis

Evaluation: History CBC with diff (suggests bacterial infection),

CXR, blood culture, urine culture, consider LP

SEPSIS

Diagnosis: blood culture Management: early detection Treatment: antibiotics for 10-14 days

Early onset: combination of ampicillin and gentamicin or ampicillin and

amikacin

Late onset: vancomycin ( gram + )

meropenem, cephalosporins, carbapenem (gram - )

Complications of Sepsis:

Bacterial meningitis DIC Septic shock Multiple organ failure

CONGENITAL INFECTION

TORCHS Toxoplasmosis Others: Hep B, Varicella, HIV Rubella CMV Herpes simplex Syphilis

TOXOPLASMOSIS

TRIAD: Chorioretinitis

obstructive hydrocephalus, intracranial calcifications

Confirmed by serologic testing

SYPHILIS

Early s/sx: osteochondritis, hemolytic anemia, hemorrhagic retinitis (snuffles)

Late s/sx: hutchinson’s teeth, healed retinits, 8th nerve deafness, saddle nose, saber chin, hydrocephalus

Peeling of skin in NB is highly suggestive of SY

RUBELLA

Sensorineural hearing loss, catarcats, congenital heart defects (PAS or PDA)

CYTOMEGALOVIRUS

Jaundice with hepatosplenomegaly, thrombocytopenia, severe CNS disease (microcephaly, subependymal intracerebral , periventricular calcifications, chorioretinitis, progressive sensorineural hearing loss)

HERPES SIMPLEX VIRUS

May be localized (discrete vesicles to large bullous lesions, keratoconjunctivitis, chorioretinitis) or disseminated involving the liver, adrenal and CNS

Common shared features suggesting Intrauterine infections

Prematurity IUGR Hematologic – anemia, thrombocytopnia, petechiae,

purpura Ocular – microphthalmia, cataracts, keratoconjunctivitis CNS – microcephaly, hydrocephaly, intracranial

calcifications Other organ systems – pneumonia, myocarditis,

nephritis, hepatospenomegal, jaundice Non-immune hydrops

Cutaneous manifestations of some organisms causing Sepsis:

Ecthyma gangrenosum – Pseudomonas sp. Salmon pink papules – Listeria

monocytogenes Vesicular rash – Herpes virus Blueberry muffin rash – CMV, Rubella,

Parvovirus

Prevention and treatment:

SYPHILIS Penicillin

TOXOPLASMOSIS Sulfadiazine / pyrimethamine

RUBELLA Immunization is recommended

CMV Gancyclovir for severe cases

HSV Acyclovir CS (preferred route of delivery)

Other Neonatal infections:INFECTION CAUSE S/SX

Omphalitis Inadequate care of cord Localized erythema, may spread to abdominal wall, peritoneum, umbilical or portal vessels

Oral thrush Candida albicans infection (DOC: nystatin)

Whitish patches on side of tongue, gingival or buccal mucosa

Neonatal tetanus Unclean delivery and unhygienic management of cord

Usually in mothers with no tetanus vaccine

Seen in 3-10 days

Inability to suck, spasms, stiffness, seizures

Other Neonatal infections:INFECTION CAUSE S/SX

Pneumonia Diffuse alveolar or interstitial disease; usually asymmetric and localized

Poor feedingLethargyIrritabilityCyanosisResp distress

Meningitis Common in late onset sepsis

Poor activity, irritability, apnea, cyanosis, tense fontanels, seizures

Necrotizing enterocolitis Risk factors ( 6 Is)ImmaturityIschemiaInfectionIntakeImmunityInflammatory mediators

Abdominal distentionPassage of blood streaked stoolsPneumatosis intestinalisPneumoperitoneumPortal vein gas

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