Neonatology

The perfect care for both low and high risk newborn infants depends on knowledge of the family history , the history of prior and current pregnancies and the events of labor and delivery . There are some significant influences that may result in poor neonatal outcome like : poor maternal nutrition , poverty , physical or psychological stresses , extremes of maternal age ( <16 yr , > 35 yr ) , black race , medical illnesses present prior pregnancy , obstetric complications during the antepartum and intrapartum periods , and the inherited genetic predisposition to the fetus . Perinatal period : is defined as the period from the 28 wk of gestation through the 7th day after birth ( additional definition include the 20th wk of gestation to the 7th days , and the 20th wk of gestation to the 28th day ) . Neonatal period : is defined as less than 28th day of life and may be further subdivided into :- Period 1 = birth to less than 24 hr , Period 2 = 24 hr to less than 7 days and Period 3 = from 7 days to less than 28 day of life .

Major causes of perinatal and neonatal mortality : Perinatal mortality : refers to the fetal deaths occurring from the 20th wk of gestation until the 7th or ( 28th day ) after birth and is expressed as number of death per 1000 live birth . Neonatal mortality rate : include all infants dying during the period beginning after birth and continuing up to the first 28 days of life also it is expressed as number of death per 1000 live births . Postnatal period : which begins after 28 days of life and extend to the end of the 1st year of life . Infant mortality rate : include both the neonatal and the post-neonatal period and also expressed as number of death per 1000 live birth . Major causes of perinatal and neonatal mortality : Fetal Preterm Full term -placental insufficiency -severe immaturity - cong. Malf. -intrauterine infections - R.D.S. - birth asphy. -severe congenital - I.V.H. - infections malformation

- Umbilical cord accidents - congenital anomalies - meconium aspiration pneumonia Abruptio placenta - infections - persistent pul. HT . Hydropis fetalis - B.P.D. Birth weight :- Normal birth weight for full term neonate is range from 2500 gm -4500 gm ( some time 4300 gm or 4000 gm accordingly ) . Low birth weight (L.B.W.) < 2500 gm ( 1500-2500 gm ) . Very low birth weight (V.L.B.W.) < 1500 gm ( 1000-1500 gm ) . Extreme low birth weight (E.L.B.W.) < 1000 gm . Large for gestational weight neonate > 4300 gm or > 4500 gm . Maturity :- Mature or term delivery : completed 38 wks from the first day of the last menstrual period . Preterm delivery : occurs less than 37 completed wks from the first day of the last menstrual period

Post –term delivery : delivery occurs 42 wks or more from the first day of the last menstrual period . Evaluation of the newborn :- Features of the newborn examination that differ from those of children and adolescents include : A- General appearance : 1- careful observation is necessary to assess spontaneous activity , passive muscle tone , respirations , and abnormal signs , such as cyanosis , intercostal muscle retractions , or meconium staining . 2- Apgar score : are a simple , systematic assessments of intrapartum stress and neurologic depression at birth , conducted at 1 and 5 minutes after birth . A persistently very low Apgar score indicates the need for resuscitation , and scoring should be continued every 5 minutes until a final score of 7 or more is reached .

Apgar score 2 1 Score H.R. >100/min <100/min Absent Score >100/min <100/min Absent H.R. Good , crying Slow , irregular Respiration Active motion Some , flexion Limp Muscle tone Cough , sneeze ,cry Grimace No response Reflex Irritability Completel pink Body pink ,blue extremeties Blue , pale Color

Apgar score are generally obtained and totaled at 1 min and 5 min following birth , and scores should be recorded for longer periods ( at 10 , 15 and even 20 min ) if they are low ( until the score is about or more 7 ) . Score of 0-3 indicate that neonate required immediate resuscitation , 4-7 required observation and admission to N.I.C.U. and 7-10 indicate good condition . B- Skin examination : Texture differ with gestational age ; skin is softer and thinner in premature infant . 1- Lanugo hair : is the thin hair that covers the skin of preterm infants . It is minimally present in term infants . 2- Vernix caseosa : is a thick , white , creamy material found in term infants ; it covers large areas of the skin in preterm infants . It is usually absent in post-term infants . 3- Color : is pink a few hr after birth , but acrocyanosis : is cyanosis of the hand and feet , it is very frequent during the first 48-72 hr and in some infants it can last throughout the first month of life , particularly when the infant is cold . Acrocyanosis and cutis marmorata ( mottling of the skin with venous prominence ) are frequent intermittent signs of the vasomotor instability . 4- Pallor : may be a sign of neonatal asphyxia , shock , sepsis or anemia .

Preterm newborn

Fat Necrosis

Vernix caseosa

5- Jaundice : is always abnormal if detected with in the first 24 hr of life . 6- Milia : are very small cysts formed around the pilosabaceous follicles which appear as tiny , whitish papules that are seen over the nose , cheeks , forehead and chin . They usually disappear with in few wks and do not require treatment . 7- Mongolian spots : are dark blue hyperpigmented macules over the lumbosacral area and buttock of no pathologic significant , these most frequently seen in Asian , Hispanic and African – American infants . 8- Pastular melanosis : is a benign transient rash characterized by small , dry superficial vesicles over a dark macular base . 9- Erythema toxicam neonatorum : is a benign rash seen most frequently in the first 72 hr after birth , characterized by erythematous macules , papules and pastules .( resembling flea bites ) present on the trunk and extremities but not on the palms and soles . The rash occur in about 50% of full term infants and found much less frequently in preterm infants . Lesions are filled with eosinophils , and culture of the fluid content is negative or sterile .No treatment is required .

Milia

Port wine stain hemangioma , mongolian spot

Mongolian Spot

Milia , erythema toxicum

Erythema toxicum

10- Nevus simplex : or Salmon patch or stork bites : it is telangiectatic nevus , it is the most common vascular lesion of infancy , occurring in about 30-40% of newborns and appearing as a pink macular lesion on the nape of the neck ( stork bite ) , upper eyelids , glabella , or nasolabial region , it is usually transient lesion . 11- Nevus flammeus or port wine stain : it is congenital vascular malformation composed of dilated capillary vessels ( a form of capillary hemangioma ) , it may be associated with intracranial or spinal vascular malformations , seizures , and intracranial calcifications ( Sturge – Weber syndrome ) . 12 – Strawberry hemangiomas . 13- Neonatal acne : occurs in approximately 20% of newborns. It appears after 1-2 wk of life and is virtually never present at birth , typically the lesions are comedones , but inflammatory pustules and papules may be present . No treatment is necessary .

Erythema toxicum , physiological desquamation