Complications of Term Newborn PDF

# 2024 Complications of Term Newborn ## Respiratory Distress * **Etiology:** Alveoli expand, lung fluid is cleared, and surfactant prevents alveolar collapse. * **Signs and Symptoms:** Hypoxemia, compensatory tachypnea, nasal flaring, chest wall retractions, and grunting. * **Complications:**...

# 2024 Complications of Term Newborn ## Respiratory Distress * **Etiology:** Alveoli expand, lung fluid is cleared, and surfactant prevents alveolar collapse. * **Signs and Symptoms:** Hypoxemia, compensatory tachypnea, nasal flaring, chest wall retractions, and grunting. * **Complications:** 1. Transient tachypnea of the newborn (TTN) 2. Meconium aspiration syndrome 3. Pneumonia 4. Pneumothorax 5. Others: RDS, persistent pulmonary hypertension, acid/base disturbances, CNS insults, congenital chest, respiratory tract, CNS, or cardiac anomalies. ## Respiratory Distress Syndrome * **Definition:** Surfactant deficiency. * **Risk Factors:** Male gender, white race, maternal diabetes, mutations in genes that code for surfactant protein synthesis (surfactant protein B, surfactant protein C, adenosine triphosphate (ATP)-binding cassette subfamily A member 3 (ABCA3), and thyroid transcription factor 1 genes). * **Differential Diagnosis:** Bacterial pneumonia. * **Diagnostic Workup:** Chest X-ray. * **Treatment:** CPAP or mechanical ventilation, surfactant replacement: endotracheal tube or invasive surfactant techniques, empirical antibiotics. * **Prognosis:** Depends on the cause, severity, and response to treatment. ## Meconium Aspiration Syndrome (MAS) * **Definition:** Inhalation of meconium-stained fluid at or near delivery causes acute airway obstruction, chemical pneumonitis, surfactant dysfunction or inactivation, and pulmonary hypertension. * **Incidence:** 4 cases per 1000 newborn * **Risk Factors:** Post-term pregnancy and fetal-growth restriction, diminished amniotic fluid and labor with cord compression or uteroplacental insufficiency. * **Diagnosis:** Fetal hypoxic episodes, and fetal heart rate tracing abnormalities. * **Treatments:** CPAP, intubation, and mechanical ventilation, surfactant replacement, inhaled corticosteroids, MAS + pulmonary hypertension: inhaled nitric oxide, ECMO. * **Prognosis:** Severe, hypoxemia may lead to neonatal death or long-term neurological sequelae. * **Prevention:** Oropharyngeal suctioning at the perineum: standard care, endotracheal intubation and suctioning, effective positive pressure ventilation, intrapartum amnioinfusion. ## Neonatal Encephalopathy and Cerebral Palsy * **Definition:** "Brain injury," and intellectual disability, neonatal encephalopathy. * **Risk Factors:** Complex multifactorial processes caused by a combination of genetic, physiological, environmental, and obstetrical factors. * **Neonatal Findings:** * **Apgar score:** <5 at 5 and 10 minutes * **Umbilical arterial acidemia:** pH <7.0 and/or base deficit ≥12 mmol/L * **Neuroimaging evidence of acute brain injury:** MR imaging or MRS consistent with HIE * **Multisystem involvement consistent with HIE** * **Type and Timing of Contributing Factors:** * Sentinel hypoxic or ischemic event occurring immediately before or during delivery * Fetal heart rate monitor patterns consistent with an acute peripartum or intrapartum event ## Neonatal Encephalopathy * **Definition:** Syndrome of neurological dysfunction identified in the earliest days of life in neonates born at ≥35 weeks' gestation. * **Incidence:** 1 to 2 cases per 1000 term liveborn. * **Risk Factors:** HIE, maternal history, obstetrical antecedents, intrapartum factors, placental pathology. * **Sentinel Events:** Ruptured uterus, severe placental abruption, cord prolapse, and amniotic fluid embolism, prior or emergent cesarean delivery, maternal age ≥35 years, maternal obesity, thick meconium, chorioamnionitis, and general anesthesia. * **Signs and Symptoms:** Seizures or subnormal levels of consciousness, often accompanied by difficulty with initiating and maintaining respiration and depressed tone and reflexes. * **Diagnosis:** * **Mild:** Hyperalertness, irritability, jitteriness, and hypertonia and hypotonia. * **Moderate:** Lethargy, abnormal tone and occasional seizures. * **Severe:** Coma, multiple seizures, and recurrent apnea. * **Only spastic quadriplegic type can result from acute peripartum ischemia.** * **Differential Diagnosis:** Genetic origin: Purely dyskinetic or ataxic cerebral palsy, with a learning disorder. ## Cerebral Palsy * **Definition:** Group of non-progressive disorders of movement or posture caused by abnormal development or damage to brain centers for motor control. * **Classification:** * **Type of neurological dysfunction:** Spastic, dyskinetic, or ataxic. * **Number and distribution of limbs involved:** Quadriplegia, diplegia, hemiplegia, or monoplegia. * **Spastic quadriplegia:** Major, most common, strong association with mental retardation and seizure disorders. * **Diplegia:** Common in preterm or low-birthweight neonates. * **Incidence:** 3 cases in 1000 children. * **Prevalence:** Only 1.6 cases of cerebral palsy per 10,000 deliveries, attributable solely to intrapartum hypoxia. * **Risk Factors:** * Evidence of genetic abnormalities such as maternal mental retardation or fetal congenital malformations. * Birthweight <2000 g. * Birth before 32 weeks. * Perinatal infection. **Note:** Preterm birth: single most important risk. * **Prevention:** Continuous intrapartum electronic FHR monitoring? ## Neonatal Abstinence Syndrome * **Definition:** Drug-withdrawal syndrome that most commonly follows in-utero exposure to maternal opioids, alcohol or benzodiazepines. * **Incidence:** 4 percent of all neonatal intensive care units. * **Signs and Symptoms:** Hypertonia, autonomic instability, irritability, poor sucking reflex, and seizures. * **Treatment:** Close observation and pharmacotherapy (morphine and methadone, other treatment: phenobarbital, benzodiazepines, and clonidine) buprenorphine. ## Hematological Disorders: Anemia * **Definition:** Below 14 g/dL after 35 weeks (n=17 g/dL) * **Risk Factors:** * Neonatal anemia may reflect an extension of antenatal fetal anemia. * Immune-mediated red cell destruction, aneuploidy, hematology-related genetic defects, fetomaternal hemorrhage, fetal infection, and placental abnormalities such as chorioangioma or twin anastomotic defects. * At delivery, acute anemia with hypovolemia can follow laceration of the placenta, fetal vessel, or umbilical cord. Intracranial or extracranial injury or trauma to fetal intraabdominal organs also can cause hemorrhage with acute anemia. * **Prevention:** Delayed umbilical cord clamping: 30 to 60 second delay. ## Polycythemia * **Definition:** Hematocrit rises above 65 (blood viscosity markedly increases). * **Risk Factors:** Associated with chronic or acute fetal hypoxia, twin anemia-polycythemia syndrome, maternal diabetes or hypertension, placental- and fetal-growth restriction, aneuploidy, and delayed cord clamping. * **Signs and Symptoms:** Hypotonia, a ruddy complexion (plethora), respiratory distress with cyanosis, jitteriness, or hypoglycemia; hyperbilirubinemia (shorter life span of macrocytic fetal erythrocytes); blood hyperviscosity can lead to end-organ damage and neurodevelopmental harm. * **Treatment:** Isovolemic partial exchange transfusion (PET: reserved for neonates with acute symptoms or hypoglycemia) with saline: lower the hematocrit and improve symptoms (not neuroprotective). ## Hyperbilirubinemia * **Definition:** Excessive serum bilirubin levels (3-4 days) & neurotoxic for newborns. * **Incidence:** 15 percent of term newborns. * **Risk Factors:** Incomplete hepatic maturation, polycythemia, hemolysis such as from ABO incompatibility or glucose-6-phosphate dehydrogenase deficiency, and extravasation of blood: cephalohematoma, continuing hemolysis. * **Signs and Symptoms:** Jaundice. * **Diagnosis:** Serum bilirubin: 10 mg/dL. * **Acute bilirubin encephalopathy:** Develops in the first days of life, with hypotonia, poor feeding, lethargy, and abnormal auditory-evoked responses. * **Chronic/Kernicterus:** Profound neuronal degeneration follows bilirubin deposition and staining of the basal ganglia and hippocampus with spasticity, muscular incoordination, and varying degrees of mental deficiencies. * **Treatment:** Surveillance for jaundiced skin & newborn vital signs, phototherapy: "bili-lights" emit a spectrum of 460 to 490 nm, which augments bilirubin oxidation to enhance its renal clearance and lower serum levels. * **Prevention:** Effective breastfeeding to avoid neonatal dehydration, transcutaneous bilirubinometry, filtered sunlight: raises peripheral blood flow, which further enhances photo-oxidation. ## Vitamin K Deficiency Bleeding (VKDB) * **Definition:** Spontaneous internal or external bleeding, onset: early, classic, or late onset. * **Etiology:** Results from abnormally low levels of the vitamin K-dependent clotting factors. * **Early onset:** Within the first 24 hours: maternal vitamin K deficiency. * **Risk Factors:** Newborns are vitamin K deficient due to insufficient antenatal liver stores, limited synthesis in an initially sterile gut, and low vitamin K content in breast milk. * **Diagnosis:** Classic hemorrhagic disease: usually apparent between days 2 and 7 of life in neonates not given vitamin K prophylaxis at delivery. * **Delayed hemorrhage:** Occur at 2 to 12 weeks in exclusively breastfed infants. * **Prevention:** Routine prophylaxis with a single, intramuscular, 0.5- to 1-mg dose of vitamin K1 (phytonadione). ## Thrombocytopenia * **Definition:** Abnormally low platelet concentrations in term newborns. * **Categories:** * **Early onset:** Within the first 72 hours. * **Late onset:** > 72 hours * **Risk Factors/Cause:** * Immune disorders, infections, inherited platelet defects, or congenital syndromes. * Immunologic sources: Neonatal thrombocytopenia, alloimmunization, maternal idiopathic thrombocytopenic purpura: antiplatelet IgG transferred to the fetus may cause accelerated platelet destruction; extension of fetal infection with B19 parvovirus, cytomegalovirus, toxoplasmosis, maternal antiretroviral therapy for human immunodeficiency virus (HIV) infection. * Sepsis can have accelerated platelet consumption. * Inherited platelet disorders. ## Newborn Injuries: Cranial Injuries * **Definition:** Traumatic head injuries that result in bony fracture or in intracranial or extracranial hemorrhage. * **Incidence:** 2 percent of deliveries. **Table 33-4. Major Types of Cranial Hemorrhage** | Type | Collection Site | Associations in Term Neonates | Clinical Outcomes | |-------------------------------|-------------------------------------------------------------------------------------|----------------------------------------------------------------------------------|---------------------| | **Intracranial** | | | | | Epidural | Between periosteum and dura mater | Difficult or prolonged birth | Usually good | | Subdural | Between dura and arachnoid mater | Idiopathic | | | Subarachnoid | Between arachnoid and pia mater | | | | Intraventricular | Ventricles (lateral, 3rd, or 4th) | Birth trauma, hypoxia, or coagulation dysfunction | Variable; worse with high IVH grade and thalamic source | | Intracerebral | Cerebral parenchyma | Coagulation dysfunction, vascular anomalies, intrapartum factors | Variable; affected by size, location, or comorbid hydrocephalus | | Intracerebellar | Cerebellar parenchyma | Abnormal FHR, OVD, resuscitation required | Variable; affected by size and comorbid lesions | | **Extracranial** | | | | | Cephalohematoma | Subperiosteal | OVD, especially VAD, dystocia | Good; risk of anemia or hyperbilirubinemia | | Subgaleal | Betweeen galea aponeurotica and periosteum | OVD, especially VAD, dystocia | Variable; worse with associated acidosis, hypovolemia, and comorbid lesions | * **OVD:** Operative vaginal delivery. * **VAD:** Vacuum-assisted delivery. ## Intracranial Hemorrhage * **Risk Factors/Etiology:** Related to gestational age: term: subdural and intracerebral, birth trauma: most frequent etiology, acquired or congenital fetal coagulopathy, vascular anomaly, tumor, genetic mutation, infection. * **Signs and Symptoms:** Seizures, apnea or tachypnea, poor feeding, and temperature instability. * **Diagnostic Workup:** Sonography or CT, MRI (preferred). * **Treatment:** Supportive and nonsurgical, prompt surgery: acute hydrocephalus, rising intracranial pressure, or mass effects. * **Prognosis:** Good: asymptomatic. ## Intracranial Hemorrhage * **Subdural Hemorrhage:** * Blood collects between the dura and arachnoid mater. Prolonged and difficult delivery can produce cranial molding, dural stretch, and tearing of bridging veins in the subdural space. * **Subarachnoid Hemorrhage:** Collects between the arachnoid and pia mater. * **Epidural Hemorrhage:** Collects outside the dura mater and beneath the periosteum. * **Intraventricular Hemorrhage:** * Choroid plexus, thalamus, or residual germinal matrix are bleeding. * Etiology: Birth trauma, hypoxia, or coagulation dysfunction. * Prognosis: Worse: advanced hemorrhage grade or thalamic hemorrhage. * **Intracerebral Hemorrhage:** * Neonatal hemorrhagic stroke, uncommon at term. * Risk factors: Coagulation defects, vascular anomalies and intrapartum factors that include FHR abnormalities and low Apgar scores. Trauma is less often implicated. * Prognosis: Affected by lesion size, presence of additional hemorrhage sites, and associated hydrocephalus or elevated intracranial pressure. ## Extracranial Hemorrhage * **Definition:** Blood collections accumulate outside the calvarium. * **Caput Succedaneum:** Soft-tissue edema of the scalp from repetitive contractions that press the head against an unyielding cervix. * Prognosis: Disappears within hours or days. * **Cephalohematoma:** A cranial subperiosteal hematoma, 1 percent and makes up a large percentage of birth injuries, etiol: laceration of the emissary or diploic veins. * Risk Factors: Dystocia, operative vaginal delivery (>vacuum). * Hemorrhage can be over one or both parietal bones, but collections do not cross suture lines. * **Subgaleal Hemorrhage:** Rare emissary vein laceration and bleeding between the galea aponeurotica and the skull periosteum. Hypovolemia/shock, 15% mortality, 0.05% of SVD, 10x more in vacuum. * **Diagnostic Workup:** Head ultrasound, CT or MR. ## Skull Fractures * **Incidence:** Rare. Worrisome because of their association with intracranial hemorrhage. * Birth-related skull fracture: 1 case per 100,000 births. * **Risk Factors:** Operative vaginal delivery, spontaneous or cesarean delivery, tight skull compression against the bony pelvis, by hand pressure used by the surgeon to lift the head at cesarean delivery, or from transvaginally applied upward hand pressure. * **Diagnostic Workup:** Radiographs or CT. * **Treatment:** Managed expectantly or require surgery. * **Prognosis:** Mainly influenced by comorbid intra- or extracranial injuries. ## Spinal Cord Injury * **Definition:** Overstretch of the spinal cord and its associated hemorrhage and edema. * **Risk Factors:** Cervical spine: most often injured, excessive traction, rotation, or hyperextension during shoulder dystocia manipulations, breech vaginal delivery, and operative vaginal delivery. * **Treatment:** Ventilator support coupled with corticosteroids or therapeutic hypothermia. * **Prognosis:** Upper cervical spinal cord injury: often fatal, and survivors can be quadriplegic. ## Peripheral Nerve Injuries: Brachial Plexopathy * **Definition:** Injury of a single nerve or can affect a nerve root, plexus, or trunk. Injury damages the nerve roots that supply the brachial plexus-C5-8 and T1. * **Erb Palsy:** C5-6, breech delivery, paralysis of the deltoid, infraspinatus, and flexor muscles of the forearm: upper trunk. * **Klumpke Palsy:** Lower plexus, hand is flaccid. * **Horner Syndrome:** Phrenic nerve damage can cause ipsilateral diaphragm paralysis, or injury to sympathetic nerve fibers, ptosis, miosis, and anhidrosis. * **Incidence:** 1.3 per 1000: SVD; 0.2 per 1000 CS. * **Risk Factors:** Shoulder dystocia, labor dystocia, and breech delivery. * **Diagnostic Workup:** Chest radiography, MRI. * **Prognosis:** Hemorrhage and edema, axonal function: good; avulsion: poor. ## Peripheral Nerve Injuries: Facial Paralysis * **Definition:** Facial nerve injury as it emerges from the stylomastoid foramen. * **Incidence:** 0.3 cases per 1000 term births. * **Risk Factors:** Pressure from the forceps blade. * **Prognosis:** Spontaneous recovery within a few days is the rule. ## Fractures * **Definition:** Long-bone fractures. * **Clavicular Fractures:** Common, unpredictable, and unavoidable; complications of normal birth. * 5 cases in 1000 live births, 10x in SVD (esp shoulder dystocia) than CS(LGA). * **Humeral Fractures:** Breech delivery or posterior arm delivery during shoulder dystocia release. * **Femoral Fractures:** Breech presentation. * **Rib Fractures:** CPR, compression forces to the chest during difficult birth or shoulder dystocia. * **Risk Factors:** Difficult deliveries. * **Diagnostic Workup:** Palpation of the clavicles and long bones, overlying crepitation or irregularity, radiography. ## Soft Tissue Injury * **Definition:** Intra-abdominal hemorrhage: liver, spleen, or adrenal glands. * **Risk Factors** Difficult delivery, especially those presenting breech; cardiac resuscitation; macrosomia or pathologic enlargement of the involved organ. * **Diagnostic Workup:** Retroperitoneal bleeding: bruising of the flanks, umbilicus, groin, upper thigh, or scrotum. * **Treatment:** Hemodynamic resuscitation and control of bleeding. ## Congenital Deformity Injuries * **Risk Factors:** Chronic oligohydramnios, multifetal gestation, or abnormally shaped or small uterine cavity. * **Congenital Torticollis:** One sternocleidomastoid muscle fails to elongate sufficiently. * Head gradually turns toward the side of the injury. * Risk Factors: Breech presentation, operative vaginal birth, or difficult delivery, uncomplicated birth and intrauterine positioning, genetics, and ischemia. * Early physical therapy. * **Talipes Equinovarus (clubfoot) and Oligohydramnios Sequence:** * **Congenital Hip Dislocation:** Strongly associated with an in-utero breech presentation. * **Treatment:** Observation or bracing. # 2024 The Preterm Newborn ## Complications of Prematurity * Respiratory distress syndrome (RDS) * Bronchopulmonary dysplasia (BPD) * Pneumothorax * Pneumonia/sepsis * Patent ductus arteriosus (PDA) * Necrotizing enterocolitis (NEC) * Retinopathy of prematurity (ROP) * Intraventricular hemorrhage (IVH) * Periventricular leukomalacia (PVL) * Cerebral palsy (CP) * Neurodevelopmental Impairment (NDI) ## Respiratory Distress Syndrome * **Definition:** Seminal complication of the preterm newborn, AKA hyaline membrane disease. Surfactant is inadequate, hyaline membranes form in the distal bronchioles and alveoli. * **Etiology:** Immature lungs: unable to sustain necessary oxygenation due to surfactant deficiency, mutations in surfactant protein production and the phospholipid transporter (ABCA3). * **Risk Factors:** Sepsis, pneumonia, or meconium aspiration, pneumothorax, persistent fetal circulation, heart failure, and congenital malformations: diaphragmatic hernia. * **Signs and Symptoms:** Tachypnea, chest wall retracts, nostril flaring, grunting. * **Complications:** Hypoxia, pulmonary hypertension and neurologic damage, cerebral palsy, hyperoxia, bronchopulmonary dysplasia, necrotizing enterocolitis, periventricular leukomalacia, and retinopathy of prematurity. * **Diagnostic Workup:** Chest radiograph: diffuse reticulogranular infiltrate and an air-filled tracheobronchial tree: air bronchograms. ## Necrotizing Enterocolitis (NEC) * **Definition:** Newborn bowel disorder. * **Risk Factors:** * Low-birthweight, perinatal hypotension, hypoxia, sepsis, umbilical catheterization, exchange transfusions, blood transfusions, and the feeding of cow milk and hypertonic solutions. * Multifactorial: and genetic disposition, intestinal immaturity, imbalance in microvascular tone, abnormal microbial colonization in the intestine, exposure to enteral feeds, and highly immunoreactive intestinal mucosa. * **Signs and Symptoms:** Abdominal distention, emesis, ileus, bilious gastric aspirates, and bloody stools. * **Diagnostic Workup:** Radiological images show pneumatosis intestinalis, which is bowel wall gas derived from invading bacteria, hepatobiliary gas and pneumoperitoneum. * **Treatment:** Prompt resection: bowel perforation, drain placement, exploratory laparotomy with resection of diseased bowel, or enterostomy. Abdominal decompression, bowel rest, broad-spectrum antibiotics, and parenteral nutrition. * **Incidence:** 1 to 10 per 1000 live births. ## Retinopathy of Prematurity (ROP) * **Definition:** AKA: retrolental fibroplasia. * **Incidence:** Largest single cause of blindness. * **Risk Factors:** Hyperoxemia, extremely preterm. * **Prevention:** Anti-VEGF therapies. ## Brain Disorders * **Definition:** Intraventricular hemorrhage, cerebellar hemorrhage, periventricular hemorrhagic infarction, cystic periventricular leukomalacia, and diffuse white matter injury. * **Diagnostic Workup:** Cranial sonography; serial, Because cystic injuries may take 2 to 5 weeks to evolve. * **Prognosis:** Adverse neurodevelopmental outcomes, develop cerebral palsy (CP). ## Intracranial Hemorrhage * **5 Categories:** * **Subarachnoid Hemorrhage:** More common in those born preterm, benign. * **Cerebellar Hemorrhage:** More frequent in preterm neonates and is increasingly recognized as a cause of serious sequelae. * **Intraventricular Hemorrhage (IVH):** Almost exclusively seen in preterm newborn, with serious effects. * **Subdural Hemorrhages:** More frequent in term newborns and can be serious. * **Intraparenchymal Hemorrhage:** More frequent in those born at term and is of variable concern. ## Intraventricular Hemorrhage * **Definition:** Fragile capillaries in the germinal matrix rupture, blood escapes into the ventricular system. * **Risk Factors:** Germinal matrix capillary network is fragile. Subependymal germinal matrix provides poor support for the vessels coursing through it, stasis and congestion, vessels susceptible to bursting if intravascular pressure rises, vascular autoregulation is impaired in the preterm neonate. * Before 32 weeks and before 27 weeks. * Hypoxic-ischemic events, carbon dioxide elevations, anatomical factors, blood pressure instability, coagulopathy, genetic factors. * **Prognosis:** Venous infarction and hemorrhage, termed periventricular hemorrhagic infarction, hydrocephalus or in degenerated cystic areas termed periventricular leukomalacia (PVL: cystic areas deep in brain white matter) ## Cerebral Palsy * **Definition:** Chronic movement or posture abnormalities that are cerebral in origin, arise early in life, and are non-progressive. * **Incidence:** 3 cases in 1000 children. * **Risk Factors:** Intraventricular hemorrhage, ischemia, Perinatal Infection/Inflammation. * **Prevention:** Neuroprotection: antenatal magnesium sulfate and corticosteroids, erythropoiesis-stimulating agents (ESAs) such as erythropoietin and darbepoetin * Neonates >36 weeks, induced hypothermia for neuroprotection is not recommended for preterm newborns.