Brandi Page, M.D.

• Associate Residency Program Director, Radiation Oncology Residency, Johns Hopkins University School of Medicine
• Assistant Professor of Radiation Oncology and Molecular Radiation Sciences

https://www.hopkinsmedicine.org/profiles/results/directory/profile/10000789/brandi-page

Management involves removing the noxious stimulus symptoms narcissistic personality disorder purchase generic accupril online, sitting the patient upright to lower blood pressure and aggressive antihypertensive treatment treatment diffusion order accupril with a visa. Steroid injections or surgical release is not usually necessary as most resolve spontaneously over the weeks to months following delivery medicine rock discount accupril 10mg on line. Corticosteroids symptoms rotator cuff injury cheap accupril online, as prescribed in non-pregnant patients medicine reviews buy 10 mg accupril with amex, can be given in pregnancy treatment zygomycetes order cheap accupril. Neuroimaging in pregnancy: A review of clinical indications and obstetric outcomes. Assessment of mental illness in pregnancy is important to ensure better outcomes for mothers and babies. Use of psychopharmacological treatments for mental illness in pregnancy and lactation must weigh the risks and benefits for both mother and child. Postpartum blues affect at least 50% of women, most commonly approximately 3 to 5 days postpartum. Postnatal depression affects approximately 10% of women and requires consideration of pharmacological therapy if of moderate severity. This arises out of the recognition that untreated mental illness during pregnancy impacts not just women but also their developing babies. Mental illness has been associated with an increased risk of pregnancy complications such as prematurity, low birth weight and preeclampsia. Early work in the area suggested that this transition should be considered to be a crisis moment for the family unit due to the dramatic need for change and reorganisation. However, more recent conceptualisations of the entry into parenthood offer the view that this transition is associated with the experience of stress as well as the satisfactions and rewards of parenting. Adjustment has been found to be more difficult when parenting expectations exceeded experiences in the following domains: relationship with spouse, physical wellbeing, maternal competence and maternal satisfaction. The recent focus has been on how the transition into parenthood affects the marital relationship and it has revealed a tendency towards a decline in marital satisfaction. Common areas of dispute and dissatisfaction relate to differing expectations regarding household duties, childcare, finances and sex. An Australian study of first-time fathers found that pregnancy was a time of greater emotional stress for men than the postnatal period and this was associated with changes in the marital relationship. While most couples successfully negotiate the transition into parenthood, many continue to struggle. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Schizophrenia and bipolar disorder, for instance, also carry risks in pregnancy from the illnesses themselves, as well as the medications used to treat them. While the focus of the debate around screening and psychosocial assessment in pregnancy and the postpartum revolves around maternal mental health, an ideal assessment should be broader and contain three key elements: 1. This can be done simply through enquiry at relevant points during pregnancy and potentially integrated within routine antenatal care appointments. It is characterised by lowered mood, anxiety, tearfulness, indecisiveness and insomnia. However, it is important that clinicians distinguish this from emerging depression or anxiety disorders. Both the illnesses themselves and their pharmacological treatment significantly elevate the risk of poor outcomes for both mother and child. Unplanned and unwanted pregnancies are common and relapse rates of both disorders are significantly elevated when pharmacological treatment is suspended. It is becoming increasingly clear that these disorders elevate obstetric and neonatal risks with significantly higher rates of low birth weight, intrauterine growth retardation, preterm delivery, gestational diabetes, preeclampsia, instrumental delivery, lower Apgar scores, stillbirth, infant malformation, need for neonatal resuscitation, admission to the neonatal intensive care unit and infant death. Active psychotic symptoms, in particular, have been found to increase these risks. In addition, the medications used to treat these illnesses (antipsychotics and mood stabilisers) may be associated with complications such as teratogenicity, pregnancy complications, neonatal complications and concerns about effects on longer-term adverse neurodevelopmental. Pregnancy-related changes in pharmacokinetics may also decrease medication serum levels to the point of being subtherapeutic. A range of other mental illnesses such as borderline personality disorder, eating disorders and anxiety disorders have also been associated with particular risks across pregnancy and the early postpartum. Depressive illness can be difficult to distinguish from a normal increase in emotional lability often associated with pregnancy and the postpartum. Key distinguishing symptoms include: anhedonia (loss of enjoyment and pleasure); depressive cognitions that involve a sense of worthlessness, inadequacy and hopelessness; and suicidal ideation. Common symptoms of depression such as insomnia, lethargy and appetite disturbance are less pathognomonic of depression in pregnancy, as pregnancy itself can also affect these functions. Untreated maternal depression has been associated with a range of pregnancy complications and poorer child developmental outcomes. These include gestational hypertension, preeclampsia, prematurity, low fetal growth and poorer child development. However, moderate to severe depression often requires consideration of pharmacotherapy. The difference in pregnancy is that careful consideration needs to be given to the risks and benefits for both mother and child should she be either treated or untreated. In pregnancy and the postpartum, it is also important to consider the fetus/infant and the wider family unit as an essential part of effectively managing mental illness across this period. Comorbidities such as smoking, alcohol and substance abuse, and commonly occurring risk factors such as inadequate nutrition and obesity, should always be addressed and systems established that encourage attendance at antenatal Chapter 25 Mental Health Disorders during the Perinatal Period appointments. Perinatal mental healthcare plans developed in pregnancy for management across delivery and the early postpartum are effective tools for multidisciplinary communication. Although coverage of the pharmacological treatment of mental illness and the evidence of risks in pregnancy is beyond the scope of this chapter, it is important for all clinicians to understand the principles of weighing benefits and risks in pregnancy and to ensure that where medication is prescribed, there is adequate monitoring and care and that informed consent is sought. Pharmacological treatment in pregnancy involves balancing both the risks associated with untreated mental illness for both mother and unborn child against the relatively unknown effects that pharmacological treatment of mental illness may pose for the child. In particular, there is a paucity of long-term developmental studies that examine for effects beyond pregnancy from exposure to psychopharmacological treatments. For many medications, any comfort we may have prescribing them in pregnancy and breastfeeding comes from the relative absence of negative data rather than the presence of positive data. However, for many women pharmacological treatment is essential for them to maintain mental health. For depression, this was recognised with joint guidelines for the treatment of depression in pregnancy developed and published by the American College of Obstetricians and Gynaecologists in collaboration with the American Psychiatric Association. Likewise, women with schizophrenia and bipolar disorder often cannot cease or alter their treatments as the risks of relapse are high with serious health implications. The medications used to treat these conditions (antipsychotics and mood stabilisers) do have implications for antenatal monitoring and care. Again, it needs to be remembered that pregnancyrelated physiological and pharmacokinetic changes frequently decrease the effectiveness of medications, particularly in the third trimester, and dose adjustments may need to be made. A recent Cochrane review also found preliminary evidence to support specific psychological interventions for the prevention of postnatal depression. A cautionary note is their role in prevention of the deleterious effects of maternal depression on child development with a Cochrane review failing to find any beneficial effect for child outcomes. Management of antipsychotic and mood stabilizer medication in pregnancy: recommendations for antenatal care. To ensure safety, consultation with experts in anaesthesia of pregnancy, perinatal psychiatrists and recommendations and monitoring by obstetrics is recommended before proceeding. Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting. Postnatal mental health of women giving birth in Australia 2002­2004: findings from the beyondblue National Postnatal Depression Program. Pregnancy, delivery, and neonatal complications in a population cohort of women with schizophrenia and major affective disorders. The First Time Fathers Study: a prospective study of the mental health and wellbeing of men during the transition to parenthood. A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women. Identifying and assessing mental health problems in pregnancy and the postnatal period. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. Does antidepressant use attenuate the risk of a major depressive episode in pregnancy? Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Psychosocial and psychological interventions for preventing postpartum depression. The role of oxytocin in mother-infant relations: a systematic review of human studies. While all these changes have important roles in facilitating a healthy pregnancy, they can also have undesirable consequences for maternal comfort and sometimes serious sequelae for the mother and/or developing fetus. Whether minor or serious, it is imperative that all care providers are attentive to maternal symptomatology, are able to distinguish the normal from the abnormal, take pains to alleviate symptoms where possible and provide ongoing maternal support where difficulties persist. Oesophageal reflux is particularly common and responds to antacids, H2-antagonists or proton pump inhibitors for the more severe cases. Constipation should be avoided with appropriate dietary advice but mild laxatives can and should be used if needed. More substantive abdominal pain requires clinical evaluation to exclude potentially serious causes that might impact adversely on pregnancy. Vomiting in pregnancy will aggravate the condition but is sometimes also a consequence of severe reflux. Meals should be light and avoid those foods found to be most likely to provoke heartburn. The bed should be raised at the head some 15 to 20 cm, and an extra pillow used if this is compatible with a good sleep. Even though the reflux may be more symptomatic during the day, less reflux at night may help daytime symptomatology. There is less experience with proton pump inhibitors in early pregnancy but they are commonly prescribed in late pregnancy for refractory cases not responding to other medication. It may be aggravated by dehydration with excessive vomiting in early pregnancy, iron supplementation and any relative immobility. Endometriosis, haemoperitoneum from any cause (uterine rupture, splenic artery aneurysm rupture, hepatic rupture). The pain is usually lateral to the uterus, in the groin and overlying the round ligament, which can be palpated as a tender cord. The pain is usually unilateral and is more often left-sided, perhaps associated with dextrorotation of the uterus bringing the left ligament into apposition with the peritoneum of the left anterior abdominal wall. The pain is often initiated or accentuated by sudden movement (standing up, bending, coughing, sneezing). Excessive straining may aggravate haemorrhoids and is intuitively unwise if there is any reason to suspect cervical insufficiency. Increase of dietary fibre (bran, green vegetables, dried fruit) should be the focus of therapy. The woman troubled with constipation should become familiar with the fibre content of specific foods and also what is effective for her. Suitable agents would include bulkproducing compounds (Fybogel, Metamucil, Normacol), magnesium hydroxide (milk of magnesia) and lactulose. Stimulant laxatives such as senna (Senokot) are also safe in pregnancy and may be appropriate. Treatment Treatment is to rest in a position of comfort and take analgesia with paracetamol. Usually the condition abates completely within 2 to 3 weeks, although hypertrophy and stretching of the ligaments continue. Known presence of a fibromyoma is extremely helpful in making the diagnosis, as is point tenderness over an area of the uterus in the context of an obviously healthy fetus. It is best to think of the differential diagnosis in terms of the likely organ involved and then secondarily what might cause pain at that location. Round ligament pain, miscarriage or labour, red degeneration of a fibromyoma, placental abruption, chorioamnionitis. Treatment After exclusion of more sinister causes, treatment is conservative with simple analgesia. They are most 204 Chapter 26 Common Problems in Pregnancy commonly completely asymptomatic but the woman may recognise a palpable tightness of the uterus that may be associated with mild discomfort. Sometimes Braxton Hicks contractions are more significant and the woman needs to briefly stop what she was doing. Management Braxton Hicks contractions require only an explanation and a reminder of the signs of labour. Threatened preterm labour and spurious labour are, by definition, retrospective diagnoses and will not generally be distinguishable from genuine labour until they are observed over time and labour is found not to eventuate. Recurrent spurious labour at term is a risk factor for adverse perinatal outcome and should be managed with increased fetal surveillance and consideration given to induction of labour. For example, bronchitis is probably more common, which may have implications for women who suffer from bronchial asthma (see Ch 17). Although there is a strong hereditary tendency, each pregnancy makes the condition worse. The fullness related to vulval varicosities may create alarm in the patient but a strong postural dependence (only apparent on standing) makes diagnosis relatively easy and the woman can be reassured that complete resolution is extremely likely in the puerperium. Thrombophlebitis (thrombosis) occurs in 5% of women with varicose veins, usually in the puerperium.

The pouch of Douglas is visualised by anteverting the uterus and an instrument is introduced via an accessory port to manipulate the ovaries and tubes to view the entire span of the ovary and the pelvic side walls medicine woman cast purchase accupril 10mg with mastercard. The uterosacral ligaments are assessed medications jamaica purchase accupril 10 mg amex, and the pararectal spaces symptoms 11 dpo buy discount accupril 10 mg line, the posterior vagina and rectum and sigmoid are visually inspected treatment using drugs buy accupril 10 mg cheap. There are general surgical risks symptoms vomiting diarrhea order accupril 10 mg without prescription, specific risks related to the surgery medicine bobblehead fallout 4 buy accupril 10mg without a prescription, and risks related to the patient. This may become obvious at the time of surgery or the patient may not develop symptoms until she is discharged. The patient may require a laparotomy to repair the damage, and can become systemically unwell. In severe cases there have been deaths, largely from initially unrecognised hollow viscus injuries, or catastrophic vessel damage; 50% of these injuries will occur on entry. There can be risks of persistent pain in the operated area, an incisional hernia, a nerve injury or scar-healing complications. Specific patients at increased risk are those with obesity as they are more at risk of entry complications and/or difficulty for the surgeon completing the operation, or the very thin, as they are at risk of major vessel injury on entry. Older patients are more likely to have concomitant medical problems which can trigger cardiac complications intraoperatively, and prior abdominal surgery increases the risk of adhesions and injury to organs on entry or during the case. Most laparoscopic procedures are performed as day cases, with the patient being discharged the same day. Different institutions will have different rates of overnight stay, depending on their population groups and the structure of the hospital. Most uncomplicated patients will return to work by 5 to 7 days, with more complex procedures. If endometriosis is found, it can be either resected or diathermied, and adhesions divided. Fibroids can be removed and the uterus can be removed either as a laparoscopic hysterectomy or as a laparoscopically assisted vaginal hysterectomy. Ovarian cysts or tubal pathology can be removed, and if it is necessary to remove these structures from the pelvis without spill, then a bag can be introduced into the pelvis and the specimen placed in that prior to being removed. Tubal patency can be disrupted by a tubal ligation, and can also be microsurgically re-opposed. Some urinary incontinence and or prolapse can be addressed laparoscopically, and foreign bodies can be removed. The epidemiology, pathogenesis, and diagnosis of vulvovaginal candidosis: a mycological perspective. Accuracy of reading liquid based cytology slides using the ThinPrep Imager compared with conventional cytology: prospective study. Human papilloma virus genotype attribution in invasive cervical cancer: a retrospective cross-sectional worldwide study. Health-related quality of life burden of women with endometriosis: a literature review. Rectosigmoid endometriosis: endoscopic ultrasound features and clinical implications. The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis. In the management of abnormal uterine bleeding, is office hysteroscopy preferable to sonography? A new approach to office hysteroscopy compared with traditional hysteroscopy: a randomized controlled trial. Prospective multicentre randomized controlled trial to evaluate factors influencing the success rate of office diagnostic hysteroscopy. Outpatient hysteroscopy: Factors influencing post-procedure acceptability in patients attending a tertiary referral centre. When dealing with paediatric and adolescent gynaecological issues, this may be even more complex. Gender issues of the newborn require high-level communication skills with often very anxious parents; there will often be unspoken concerns regarding long-term outcomes. Clinical examination should carefully avoid anything that may be traumatic to them. Direct and sensitive communication becomes even more important with the adolescent. Part of the consultation needs to occur without parents and include a clear discussion regarding confidentiality and the opportunity to explore issues relating to sexuality, safe sex, contraception and other adolescent health risk behaviours. Any examination needs to be very carefully considered, and often genital examinations need to be very limited. Simple follow-up with postnatal ultrasound is usually all that is required to ensure resolution occurs. These physiological ovarian cysts can occasionally precipitate ovarian torsion when the cyst becomes more complex in appearance. Antenatal diagnosis of congenital anomalies increasingly occurs and this may include conditions that impact on the reproductive tract of the fetus. Antenatal referral for discussion regarding the long-term outcomes of these conditions may be appropriate, as outlined in this chapter. This volume usually reduces over time, and the imperforate hymen is generally best managed in the peri-menarcheal age. Chapter 46 Paediatric and Adolescent Gynaecology Occasionally it can be associated with significant vaginal distension with acute urinary retention; these require drainage. Genital ambiguity this requires input from a specialist team to ensure that appropriate investigations and discussions occur. Gender uncertainty in the neonate is very challenging for all concerned and care with communication to the parents by all staff involved is essential. It is important to give parents psychological support while investigations are undertaken. Important diagnoses such as congenital adrenal hyperplasia, which can be associated with collapse and neonatal death, need to be identified. An ultrasound demonstrating an enlarged ovary should provoke serious consideration of this diagnosis with a laparoscopy to diagnose, untwist the ovary and potentially perform the ovarian cystectomy. Discordance of gender phenotype and genotype With increasing antenatal diagnosis of fetal karyotype, the possibility of a healthy-appearing baby of the opposite gender to that expected can occur. The process is initiated by the hypothalamus becoming less sensitive to negative feedback from endogenous oestrogen and progestogen. Ovulatory cycles with progesterone production often take another 1 to 3 years post-menarche. Spontaneous resolution occurs; for many during childhood, but for a small number the adhesions may persist until peri-menarcheal. Given their natural history of spontaneous resolution, no intervention is required. Investigation of early pubertal changes is influenced by the rate of changes and the clinical findings. In the prepubertal girl, the vulval and vaginal skin is relatively atrophic and thus easily irritated. Overgrowth of this flora can cause a low-grade discharge, which can irritate the thin skin; this is most apparent on the contact surfaces between the labia majora. Simple measures including bathing, with the possible addition of a small amount of vinegar to alter the vaginal pH, combined with barrier cream applied to the vulva is all that is required. Vulval swab is only required in the setting of a persistent profuse vaginal discharge. Vaginal bleeding may be associated with a foreign body or, rarely, with a vaginal tumour. Failure to have any secondary sexual characteristics by the age of 14 years and to achieve menarche by 16 years requires consideration. Hypothalamic­pituitary causes Delay in the hypothalamic initiation of pubertal changes can occur due to familial patterns (siblings or parents may be similarly affected), low body weight (eating disorder), excess exercise or a general health issue. Stage 2 breast development (appearance of the breast bud) marks the onset of gonadarche. There are often other features for this including a history of recurrent otitis media, coarctation or other cardiac problem. Other possibilities include previous chemotherapy for childhood malignancy, premature ovarian insufficiency and other gonadal dysgenesis. Menses usually starts within 2 years of breast development, but where there has been a 4-year delay then Mьllerian agenesis (uterovaginal agenesis) should be considered. A pelvic ultrasound will demonstrate normal ovaries and follicles but an absent uterus. Surrogacy gives these women the possibility of their own child as their ovarian function is normal. Uterine transplant is a novel option being explored, and may be a possibility in the distant future. Delayed menarche with atypical pubertal development Absence of secondary sexual hair the absence of pubic or axillary hair suggests a diagnosis of androgen insensitivity syndrome. In these young women, testes produced testosterone and Mьllerian inhibitory substance in utero, causing regression of the Mьllerian structures. Testosterone converts to oestrogen in peripheral fat tissue; hence, breast development occurs at puberty. Delayed menarche with normal pubertal development Delayed menarche with a history of cyclic pain suggests an obstructive problem, which may include an imperforate hymen or obstruction due to a transverse vaginal septum or cervical agenesis. If the patient is obese, weight management is the cornerstone of management for this condition. Intervention is only required if this is causing problems due to either heaviness of loss or prolonged bleeding. Cyclic progestogen therapy is usually effective with either oral medroxyprogesterone acetate 10 mg daily or norethisterone acetate 5 mg daily for 14 to 21 days per month for a few months while waiting for maturation of the hypothalamic­pituitary­ovarian axis. Heavy bleeding requires careful history because the definition of heavy loss varies, with teenagers having little experience with respect to normal menstrual loss. Where there is very heavy loss and a low haemoglobin, admission for resuscitation and transfusion is sometimes required. Tranexamic acid reduces menstrual loss by 50% and can be used for all heavy menses. For teenagers with heavy menses, an underlying bleeding disorder is present in approximately 10%. There will often be a family history of heavy periods as well as other features of a bleeding diathesis such as gum bleeds, epistaxis and easy bruising. Adolescents with heavy menses may also report a different pattern of period pain, likely to reflect retrograde bleeding and irritation of the peritoneum. Depot medroxy progesterone acetate and levonorgestrel intrauterine systems (inserted under general anaesthetic in the non-sexually active teenager) are options that are occasionally required. Secondary causes or dysmenorrhoea are uncommon (< 8%) but include obstructive congenital anomalies, ovarian cysts and endometriosis. Endometriosis has been shown to be more common in women who bleed more often and more heavily. Moderately severe endometriosis is found in adolescents with obstructive anomalies; however, after correction the endometriosis will almost always resolve spontaneously. There is also an increased rate of endometriosis in women with mild bleeding disorders. Menstrual management in the presence of an intellectual disability the age of onset of puberty and menarche are normally unchanged in adolescents with intellectual disabilities. In general, the same measures for controlling heavy or painful periods apply for these young women. In some of these young women, seizure control may fluctuate with the menstrual cycle and achieving a stable hormonal environment may assist. The aim of optimising quality of life in these young women applies just as for any patient. Sterilising procedures, including hysterectomy, endometrial ablation and tubal ligation, require approval from appropriate authorities (this varies in different parts of Australia), but these procedures are rarely required. Dysmenorrhoea Period pain or dysmenorrhoea is reported to occur in up to 80% teenage girls, with an impact on schooling and participation in physical and social activities. The majority of dysmenorrhoea is related to the physiology of the menstrual cycle, with inflammatory cytokines and prostaglandins causing the frequently associated symptoms of nausea, vomiting, diarrhoea and feeling dizzy or faint. Discussion regarding sexuality needs to be in the context of a confidential consultation. A helpful approach with the young person is to explore less-threatening issues and move to more personal topics while rapport is established. Intervention to reduce and limit these health-risk behaviours can clearly have long-term beneficial effects. There is evidence that young people who are undertaking one health-risk behaviour are likely to be doing others. Ovarian torsion the majority of ovarian torsions occur in the setting of an enlarged ovary, although this may be as a result of a physiological ovarian cyst. Examination findings are mild to moderate tenderness, so suspicion on the basis of history is important. Ultrasound allows identification of the enlarged ovary, but the presence of blood flow to the ovary does not exclude the diagnosis. Oophorectomy is not usually required, even in the setting of prolonged symptoms or an ischaemic-looking ovary, as follicles have been identified in > 90% of these ovaries on follow-up. This is normal and should not be used as an indication for further investigation, remembering that in teenagers irregular menses and some acne are also normal findings. Complex ovarian cysts may represent a haemorrhagic corpus luteum if < 6 cm and should resolve on subsequent ultrasound. Larger complex ovarian masses in young women are more likely to be germ cell tumours than the tumours that are seen in adult women. Menstruation occurs in response to progesterone withdrawal in the presence of an oestrogen-primed endometrium.

Impor tantly medicine to induce labor cheap 10 mg accupril overnight delivery, in the absence of severe blood loss treatment junctional tachycardia cheap 10 mg accupril otc, some animal studies have shown deleterious effects of fluidbolus when used in neonatal resuscitation medicine stick discount 10mg accupril free shipping. The Apgar score If present medicine zantac buy generic accupril 10 mg, the severity of birth depression can be ascer tained by a number of clinical methods treatment ulcerative colitis buy accupril 10mg otc. The Apgar score comprises assessment of five items: heart rate medications used for bipolar disorder order discount accupril, respira tory effort, muscle tone, colour and reflex response. The Apgar score is based on the degree of cardiorespiratory and neurological depression present, ventilatory resuscitation commences in air. The use of peripheral oxygen monitoring is recommended, espe cially in the context of laboured breathing and/or when resuscitating a newborn requires assisted ventilation. The use of air/oxygen mixtures allows for the titration of inspired oxygen in order to avoid over oxygenation. Initial resuscitation in 100% oxygen is not recommended; adverse outcomes including delay to establish normal respiratory state have been shown. Importantly, the ability to use air/oxygen mixtures during the resuscitation is now almost universal. Very occasionally, when the heart rate remains < 60 bpm, and despite adequate assisted ventilation, chest compressions are then required. The ratio of compressions to ventilatory breaths in neonates differs from the ratios listed in resuscitation guide lines for infants, children and adults. Chapter 64 Neonatal Physiology: Adaptation and Resuscitation and is measured at 1 and 5 minutes after birth. It is com monly measured in all babies at birth regardless of whether or not birth depression is present. A normal Apgar score is 7 to 10; a score of 4 to 6 demonstrates moderate depression and a score of 0 to 3 demonstrates severe depression. The Apgar score is useful in assessing the adequacy of resuscitation and, in some studies, has been shown to have a degree of prognostic value. Approx imately 9% of babies with an Apgar score at 5 minutes or less than 7 will have some neurological disability com pared to around 2% in the remaining population. The umbilical artery pH best reflects the metabolic state of the fetus and a pH below 7. While both Apgar scores and cord pH sampling have limitations in predicting longterm neurological outcome, in cases where birth depression is suspected both are often obtained and documented. In the event of a prolonged neonatal resuscitation, thought should be given to the cessation of resuscitation. Newborns can be resuscitated, and survive without disability, despite an Apgar score of 0 at 1 minute. General consensus is to consider ceasing resuscitation if the heart rate is undetected and remains so for 10 minutes. Clear and open discussion among the resuscitation team, as well as with the family, should guide decisions regarding starting or ceasing resuscitation. Response to resuscitation In the vast majority of cases of resuscitation, the newborn responds to adequate assisted ventilation and hence restoration of cardiorespiratory function. Subsequent increase in heart rate and improvement in cardiovascular status often ensures purely with effective ventilatory resuscitation. Ongoing research, both in Australia and internation ally, occurs to better facilitate evidencebased resuscitation guidelines (see Box 64. If there has been a significant hypoxic event and/or extensive neonatal resuscitation, clear guidelines exist to assess and offer treatment to these newborns in the immediate postnatal period. This includes post resuscitation therapeutic hypothermia, which is discussed in Chapter 69. Lastly, there may be situations where families choose not to resuscitate a newborn; for example, in extreme prematurity or in cases with known severe congenital anomalies. Conversely, lack of response to a prolonged resuscitation ultimately requires a decision to stop treat ment (see Box 64. Association of Apgar score at five minutes with longterm neurologic disability and cognitive function in a prevalence study of Danish conscripts. In Australia, various states and territories offer neonatal resuscitation training. Additionally, the Australian Resuscitation Council updates and reviews neonatal (and other) resuscitation guidelines. Routine care should: allow maternal­infant bonding promptly detect illness or abnormality of the newborn actively facilitate and support breastfeeding. Newborns should be maintained in a thermal environment that is appropriately warm, while avoiding under- or overheating. The arrival of a new member into the family causes many changes that can be the source of both joy and stress. Vitamin K is often administered intramuscularly at this time in order to prevent haemorrhagic disease of the newborn (see Chapter 74). Immediately following delivery, the newborn remains in the labour ward until it has been established that transition to extrauterine life has occurred without problems. There should be comfortable respiratory efforts and a respiratory rate less than 60 breaths per minute, with no signs of increased work of breathing or excessive mucus secretions, nor of cyanosis. Identity labels are often attached to the wrist and/or ankle of the newborn and verified against those of the mother. The newborn should be weighed and the head circumference and length measured and documented. This includes being vigilant for respiratory distress or cardiovascular compromise. Alertness, temperature, colour, heart rate and respiratory rate are routinely observed. It becomes necrotic and separates between approximately 1 week and 14 days after birth. Normal care involves keeping it clean using water at the time of routine bathing, and thoroughly drying it afterwards. Care should be taken to prevent cross-infection by disinfection of communal equipment such as baths. Unless there is an outbreak of skin infection, there is no need to use an antiseptic solution at bath time. Meconium (the thick, sticky and black stool) is passed first and continues to be passed for several days. Failure of a full-term newborn to pass meconium in the first 24 hours may indicate an anatomical or functional gut obstruction. Breastfed newborns have a variable pattern of passing stool: some pass a stool after each breastfeed (gastro-colic reflex) and some may not pass a stool for some days. There are often normal changes in the colour, consistency and frequency of stooling that occur in the days and weeks after birth; parents should be made aware of this to avoid any unnecessary worry or investigations. Urine output and frequency of wet nappies (at least two or three wet nappies per 24 hours over the first few days of life) should also be monitored in the immediate postnatal period. Nearly all newborns will pass urine sometime in the first 24 hours of life; failure to do so should be cause for concern. A failure to pass urine or reduced urine output may signal renal injury (most commonly from perinatal asphyxia-if severe enough to cause renal injury, one would expect other clinical parameters to be abnormal) or, rarely, urinary obstruction. This is normal and expected, and again parents should be made aware of this expectation. Until the birth weight is regained, it is customary to weigh the newborn every 2 to 3 days. For the first several weeks thereafter, the average weight increase is approximately 30 g/day. Neonates that remain below their birth weight at 2 weeks of age require prompt assessment. Test weighing before and after a feed, to estimate the amount of milk that a baby has taken, is rarely indicated. It tends to create high levels of anxiety without providing information which is not available in other ways. For example, dehydration is diagnosed by low urine output, poor feeding and decreased skin turgor, while inadequate nutrition is diagnosed by failure to gain weight over a period of 1 week or more. An experienced lactation consultant can provide breastfeeding support and assist in promoting milk supply, even in the context of weight loss or poor weight gain. Similarly, with the newborn at the bedside, demand breastfeeding is readily possible and the risk of cross-infection is reduced. Co-sleeping and bed-sharing practices are important issues that are often discussed and explored with families in this rooming-in setting. Co-sleeping should not be permitted in the immediate postnatal period as cases of unintentional smothering have occurred, likely due to the mother being less responsive to her infant because of exhaustion, narcotic analgesics and epidural analgesia. Various international and local policies and protocols exist to guide new mothers and clinical staff on current recommendations and practices. Issues around bonding, feeding, maternal fatigue and/or sedation, and other safety and culturally sensitive issues are important discussion points. A hat may be used for a baby that has become hypothermic, but the hat should be removed once normothermia is reached. Similarly, a well-swaddled newborn that is normothermic should have their head uncovered to prevent overheating. This form of temperature regulation is preferred over the use of overhead heat sources. As well as being a highly effective method of temperature regulation, skin-to-skin contact benefits bonding and breastfeeding. If an overhead heat source is used in the case of hypothermia, great care must be exercised if used in close proximity to the baby: burns may result. By several weeks, it is thought that a newborn can visually discriminate between their mother and a stranger. The newborn can be comforted by cuddling and rocking movements or by very gentle patting. Sleep­wake cycles are often irregular, and in the early neonatal period can be reversed. In the first few weeks after birth, the average total time spent sleeping is around 16 to 18 hours a day. Normal sleep­wake patterns, with more alert periods during the day and more settled sleep overnight, normally develop at around 4 to 8 weeks of age. Cold stress is deleterious to the newborn due to increased metabolic demand in attempting to restore normothermia; it is associated with increased mortality. Neonatal screening began in the 1960s with the work of American microbiologist Dr Robert Guthrie. While the Guthrie card remains in widespread use, technological advances have resulted in a range of newer screening techniques. Local jurisdictions govern which diseases are screened; this varies across states and internationally. Correct age, date and time of birth as well as newborn and parental information needs to be clearly documented on the card. Examination revealed: a depressed nasal bridge; puffy eyelids; thick, dry and cold skin; coarse hair; large tongue; and abdominal distension. Because hypothyroid newborns may be asymptomatic, this and some other important conditions are screened for. If any concerns about parenting skills are recognised during the hospital stay, additional support of the family should be arranged through community maternal and child health services. When a preterm or sick newborn is separated from the parents and family for a long period, special attention is required to how this stress is handled. Opportunities for family members to have physical contact with their newborn should be maximised, such as the chance to handle the sick or very preterm baby as soon as the clinical condition allows. If the baby or outcome is different from parental expectation (such as occurs when there is illness, unexpected malformation or a death), there will be additional stress. Importantly, parental stress and anxiety exist in a sociocultural milieu, and sensitivity from the clinical team is paramount. A newborn examination should be performed shortly after birth, is commonly repeated prior to the baby leaving hospital, and is performed again at 6 weeks of age. An adequate examination will assist in identifying critical issues such as sepsis or congenital cardiac disease. Conditions detected as part of the newborn examination may not always be life-threatening, but nonetheless require detection to prevent morbidity, alleviate anxiety and allow for appropriate follow-up. At term the healthy newborn is visually alert, is attentive to the sound of the human voice, sucks, uses crying as a method of communicating various needs, and is self-aware and self-protective. To maximise the value of the examination, the newborn should be in a quiet but alert state and the parents should be present. An appreciation of common normal variations is important to provide reassurance to the parents. Any pathology must be identified accurately so that a management plan can be developed; the early identification and treatment of abnormalities may reduce any associated morbidity. Were any of the following present: maternal medication, maternal drug abuse, fetal growth restriction, prematurity, maternal diabetes or other medical illness? Were there anatomical anomalies on antenatal ultrasound screening that warrant reassessment and evaluation in the newborn period? Were any of the following present: asphyxia risk factors, trauma, instrumental delivery, low Apgar scores or need for resuscitation? Often helpful parents would like to assist in the undressing, but if done competently and confidently by the examiner, much information can be gained. While undressing the newborn, and once the baby is exposed, the examiner is able to make an assessment of the general neurological state of the baby; neuromuscular tone and the degree of activity, irritability and lethargy.

Grand multiparity and previous uterine scar are predisposing factors for uterine rupture and are relative contraindications to prostaglandin administration treatment ind order accupril mastercard. Drug Salbutamol Dose 50 mcg slowly intravenously; repeated if necessary up to 250 mcg symptoms uric acid order accupril 10mg free shipping, but one or two doses usually sufficient 250 mcg subcutaneously 400 mcg sublingual or buccal spray; may be repeated once if necessary Adverse effects of prostaglandins Excessive uterine muscular activity the principle concern with prostaglandin administration is the risk of excessive uterine muscular activity treatment buy cheap accupril 10mg online. First symptoms e coli order 10mg accupril with amex, there is a reduction in uteroplacental blood flow with every uterine contraction medicine you can take while pregnant 10 mg accupril visa. If the sufficiently intensive contractions are 246 Terbutaline Glyceryl trinitrate Chapter 29 Induction of Labour administering medications 8th edition order accupril once a day, Including Cervical Ripening · Any situation where there is concern that fetal compromise will develop in the presence of increased uterine muscular activity. An unfavourable cervix in the presence of suspected placental insufficiency is probably best managed with a transcervical balloon catheter rather than prostaglandins as the likelihood of sudden severe fetal compromise with uterine tachysystole will be reduced. Technique An aseptic technique should be performed, first swabbing the vulva and vagina with aqueous chlorhexidine and then using chlorhexidine lubricant, sterile gloves and sterile implements. Most commonly, the specially designed AmniHook is used but alligator forceps are an alternative, particularly if the procedure is difficult in the presence of a cervical score that is lower than usual. After the procedure, a check for cord prolapse is made, and the fetal heart is auscultated. If the amount of liquor is greater than normal, the hand should be kept in the vagina and the liquor released slowly. Sometimes, however, it is necessary and wise to make sure the presenting part remains over the pelvic brim and the liquor drains away. Early use of an oxytocin and vertical posturing will make it less likely that the presenting part drifts into one or other iliac fossa. Pre- and post-prostaglandin fetal surveillance A reactive antenatal cardiotocograph should immediately precede the administration of prostaglandins, both the first dose and any subsequent doses. Some units have protocols that recommend repeat cardiotocographs approximately 6 hours after the administration of prostaglandins to detect fetal compromise related to uterine activity that is not otherwise apparent. All women need continuous cardiotocography in any labour subsequent to prostaglandin administration. Transcervical balloon catheter In women in whom the cervix is unfavourable, a 30-mL Foley balloon catheter is passed through the cervix. This is most often done on the evening before planned induction of labour in the presence of an unfavourable cervix. The Foley balloon is usually expelled from the lower uterine segment through the cervix overnight, leaving a cervix ripe for induction of labour the next morning. Adverse effects of a transcervical balloon catheter Infection the main concern when using a catheter for cervical ripening is that infection may be introduced and chorioamnionitis may result. However, given that even a very small number of cases of chorioamnionitis would be clinically important, those employing this technique should be vigilant in their aseptic technique and be alert to any increase in incidence of chorioamnionitis. Oxytocin infusion for induction of labour Regimen this should almost always be preceded by spontaneous or artificial rupture of the membranes, as indicated. A widely used regimen places 10 units per 1000 mL normal saline or Hartmann solution (10 units/L). If there is good progress of labour (cervical dilatation of at least 1 cm/hr) or more than four contractions in 10 minutes, the oxytocin infusion rate should not be increased. It is wise to increase the oxytocin dose only every 30 minutes, since it takes this time for plasma levels of oxytocin to reach a steady state. During the infusion, the frequency and nature of contractions should be assessed every 15 minutes. First, there is likely to be an increase in endogenous prostaglandin release which both directly augments uterine muscular activity and also increases receptivity to endogenous or exogenous oxytocin. Adverse effects of an oxytocin infusion Excessive uterine muscular activity this may result from overdosage or unusual sensitivity to oxytocin. As a consequence, the oxytocin infusion rate should be commenced at a lower rate after prostaglandin use. Hypotension Oxytocin has a mostly mildly hypotensive effect but some women exhibit greater sensitivity to this side effect. This side effect presumably relates to the fact that the structure of oxytocin is analogous to the vasoconstrictor vasopressin. Water intoxication In contrast to an apparent antagonism of the vasoconstrictor effect of vasopressin, oxytocin has an agonistic effect with respect to water retention. This is now very uncommon; however, prior to the availability of prostaglandins very high doses and prolonged use of oxytocin frequently caused serious water intoxication. Postpartum haemorrhage Oxytocin, like other hypothalamo-pituitary peptides, down-regulates its own receptor. This means that there will be reduced sensitivity to endogenous oxytocin if the high levels of infused oxytocin are ceased. The oxytocin infusion used for induction or augmentation should be continued for at least an hour after birth to assist in maintaining uterine tone and preventing postpartum haemorrhage. Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. Indications for episiotomy include to avoid a major perineal tear, expedite birth, reduce traction needed during instrumental birth and improve access for manipulative deliveries. Midline episiotomies have only a very limited place in clinical practice as there is a higher likelihood of extension into the anal sphincter. Third- and fourth-degree perineal tears require an experienced surgeon with good lighting and adequate analgesia. A cervical tear should be expected if there is brisk bleeding immediately after delivery of the baby and before the placenta has separated. A vulvovaginal haematoma usually requires a urinary catheter and conservative management is generally preferred. Expedite birth Fetal compromise and/or inadequate progress with the head on the perineum; vaginal breech delivery It is common, especially in a nulliparous woman, that an inelastic perineum will considerably delay birth, with possible consequences in terms of fetal compromise and compression injury to the nerves of the pelvic floor. Avoidance of major perineal tear Perineal tear already occurring early with head crowning; instrumental birth A small perineal tear is clearly associated with less discomfort than an episiotomy. An episiotomy will reduce the traction required, with obvious benefits for the fetus. Analgesia can be provided with local infiltration in the absence of a regional or pudendal block. The incision is made when the head bulges the perineum because it is easier to judge the proper length, the anal sphincter is displaced and blood loss is less. One blade of the scissors is inserted inside the vagina with the cutting angle resting on the fourchette. The incision is made posterolaterally at a 45° angle (at a position equivalent to 7. If delivery is not immediate, bleeding from the cut edges can be controlled by firm pressure with a gauze swab while awaiting the next contraction. Improve access for manipulative delivery Shoulder dystocia; vaginal breech delivery Occasionally, a tight perineum may make manipulative birth more difficult. Examples of this include delivery of the posterior arm in a case of shoulder dystocia (Ch 34) or delivery of the after coming head of a breech (Ch 15). The advantages of this technique are less bleeding, greater ease of repair, less pain during healing and a lower incidence of subsequent dyspareunia. If vulval varicosities are particularly severe, a midline episiotomy will reduce blood loss compared to a mediolateral episiotomy. The area near the urethral meatus and clitoris is very vascular and careful suturing is required. If the incision extends past the anus, it enters the area innervated by the perforating cutaneous nerves which are not affected by a pudendal nerve block. A Local analgesia was provided by perineal infiltration (trickle of blood marks site of injection) when the head bulged the perineum. The woman is usually in the lithotomy position but a small lesion can be repaired in the dorsal position. There must be sufficient vision to be able not only to perform the surgical repair but also to clearly identify the structures involved, particularly whether the anal sphincter has been affected (see the section on third- and fourthdegree tears later in this chapter). Catgut and chromic catgut have been shown to produce more pain in the early postnatal period. Arterial bleeding is dealt with by clamping and ligating the vessel, but oozing from epithelial and skin edges is controlled by the pressure applied by the sutures. Haemostasis is imperative, otherwise extensive bruising and haematoma formation can occur with the subsequent complications of pain, infection and disruption of the wound. Sutures are placed at about 1-cm intervals and a good bite of epithelium and submucosa is taken to obliterate dead space. Sutures should not be tied too tightly because of the swelling which occurs in the following 24 to 48 hours. Three markers should be used for accurate opposition: the vaginal apex, the hymen and the mucocutaneous junction. If the upper limit of the vaginal incision cannot be seen, a stitch is inserted as high as possible and tied; traction upon this stitch then exposes the upper limit of the incision, which is sutured. Approximation of the perineal muscles the second step is approximation of the perineal muscles. The anatomical distortion inevitable with the mediolateral incision should be allowed for as the lower elements of the levator ani muscle and the bulbocavernosus muscle are sutured. The ultimate strength of the repaired pelvic floor depends mainly upon this layer. Prevention In both the above situations, the accoucheur is responsible for effecting delivery in a controlled manner. This extends back to antenatal education and preparation of the woman for the second stage of labour. Closure of the perineal skin the third step is closure of the perineal skin, which is performed with a continuous subcuticular suture beginning posteriorly and working back towards the fourchette with absorbable suture material. Immediately after surgical closure Once surgical closure is complete, a vaginal examination ensures that no pack remains and a rectal examination excludes stitches in the rectum or anal canal. If there is persistent oozing from an episiotomy wound and/or vaginal lacerations after repair, haemorrhage can usually be controlled by insertion of a gauze pack (10 cm Ч 2 m) into the vagina. If a pack is used, an indwelling catheter is inserted because the pack will occlude the urethra and prevent voiding. Large presenting part or shoulders Large fetus; malpresentation with unfavourable diameter presenting (face to pubis) Occasionally the fetus may present with an arm alongside the head, leading to a sudden expansion of the perineum as the flexed elbow delivers. Pain is greater with larger episiotomies and much external suturing, long second stage, operative delivery and perineal bruising. Degree 1st 2nd 3rd 3A 3B 3C 4th Structures involved in the perineal tear Skin, subcutaneous tissue and superficial fascia Muscles of the perineum Anal sphincter < 50% of the external anal sphincter 50% of the external anal sphincter internal anal sphincter involvement Anorectal mucosa 253 Complications of an episiotomy Infection Infection is relatively uncommon considering the nature of the area. It usually takes the form of a stitch abscess or infected haematoma, but occasionally infection of the ischiorectal fossa may occur. Perineum less elastic Nulliparity; scarring from a previous perineal tear or episiotomy Approximately 80% of women having their first baby will have a perineal tear. The major modifications to connective tissue during pregnancy are just sufficient in most women to allow passage of the fetus through the introitus with only minor perineal tears (first or seconddegree). There are also presumably inherent individual characteristics of connective tissue that make tearing more or less likely under the same stretch impulse. There are no known effective pharmacological techniques to make the perineum more elastic and therefore prevent tears. Devices that mechanically stretch the perineum in late pregnancy may have a role but studies examining long-term consequences with respect to prolapse are awaited. However, if performed too early and too small, all the stretch will be taken in that part of the perineum and an extension, possibly through the sphincter, becomes even more likely than if there was no episiotomy at all. Therefore, the following special measures are usually undertaken for the repair of a third- or fourth-degree tear. This usually means that the procedure is performed in an operating theatre or a room in the birth suite that is equipped for such a purpose. The procedure should be either performed or supervised by an appropriately trained obstetrician. Approximation can occur either by a direct end-to-end apposition or an overlapping technique. Care in the early puerperium the use of postoperative laxatives is recommended to reduce the incidence of postoperative wound dehiscence. Intraoperative and postoperative broad-spectrum antibiotics are recommended to reduce the risk of infection, which in turn may lead to anal incontinence and fistula formation. Inclusion of metronidazole is advisable to cover the possible anaerobic contamination from faecal matter. Transient incontinence is most often a result of neuropraxia and recovers after the first couple of weeks. An unrepaired anal sphincter injury will produce continuing symptoms with incontinence of flatus and possibly faeces. A rectovaginal fistula will occur with breakdown of a fourth-degree tear but can also occur if a repair suture is placed too deep so that the suture hole can form a fistulous track. Follow-up care Follow-up visits for assessment of second- and thirddegree tears and identification of continence problems should be recommended 3 to 6 months postpartum. Counselling for future births should be considered for women with thirdand fourth-degree tears, with consideration of caesarean section for future births, especially in women with anal incontinence. Packing may be used as an emergency, but must be properly performed; it often wastes time and blood, and bimanual compression is preferable. If the bleeding is coming from inside the cervical canal, it is likely that its origin is from the placental site or a tear in the uterus; exploration will determine this. Obviously, it is preferable to secure any deep bleeding point at the base of a tear or episiotomy to avoid haematoma formation. Rarely, the haematoma may be associated with uterine rupture, in which case the vaginal haematoma will usually extend up into the broad ligament. The degree of discomfort to the woman is proportional to the size of the haematoma; if large, severe pain is experienced (classically perirectal) and shock may result. The alternative is to attempt drainage of the Technique of repair the vaginal walls are well retracted by an assistant and a systematic inspection is made of the vagina and cervix. If the bleeding is from a vaginal laceration, it is closed with a continuous or interrupted chromic catgut suture.

In the context of fetal thrombocytopenia 4 medications list accupril 10 mg on line, it is not known whether delivery by caesarean section reduces the risk of haemorrhage during delivery treatment 1 degree av block discount accupril 10mg free shipping. Exposure to maternal drugs such as thiazide diuretics and sulphonamides can lead to neonatal thrombocytopenia medications ok during pregnancy buy accupril with american express. Hence treatment tinnitus purchase accupril 10 mg overnight delivery, a platelet count < 100 Ч 109/L in the newborn is often used to define neonatal thrombocytopenia treatment resistant schizophrenia accupril 10 mg without prescription. Thrombocytopenia usually results from an increased destruction of platelets medications used to treat adhd generic accupril 10mg line, which may be due to factors in the mother, fetus or newborn. Intracranial haemorrhage is rare and haemorrhage is unlikely to develop if the platelet count is > 30 Ч 109/L. Fetusandnewborn Various diseases of the fetus and newborn can cause thrombocytopenia: infection with bacteria or viruses severe erythroblastosis (haemolytic disease) exchange transfusion platelet destruction in giant haemangiomas (Kasabach-Merritt syndrome). Causes of blood in the stool include swallowed maternal blood, disturbances of coagulation, malrotation with volvulus, necrotising enterocolitis and infection. Bloodstreaked stools could also be due to an anal fissure, but other causes (such as milk protein intolerance and necrotising enterocolitis) must be considered. Ingested blood may be from the maternal perineum at birth or from the breast (usually there is an associated cracked nipple, but spontaneous bleeding during a breastfeed may occur without the mother being aware of the occurrence). Further to the bedside clinical history and examination, laboratory tests may be required guided by the degree of clinical suspicion of the cause. These include a blood count (looking for signs of infection or thrombocytopenia), clotting studies, and/or X-ray of the abdomen. If the fetal platelets are recognised as foreign by the mother, an antibody response is mounted. Low birth weight is associated with a higher mortality than that for babies who are born heavier than 2. Low birth weight newborns comprise approximately 6% of all births but can account for up to 80% of neonatal deaths. There are two quite separate issues involved in the causation of low birth weight: prematurity and small for gestational age. Preterm newborns are prone to a particular set of problems which include hypothermia, hypoglycaemia, jaundice, respiratory distress syndrome, patent ductus arteriosus, intraventricular haemorrhage, periventricular leucomalacia, apnoea, necrotising enterocolitis and retinopathy of prematurity. A neonatal intensive care unit allows for specialised care of the premature newborn. Where the likelihood of preterm labour and delivery is suspected, specialised obstetric and neonatal care should be made available. This will necessitate moving the mother and unborn child to a specialised hospital: morbidity and mortality outcomes are improved in this way. Not all high-risk deliveries can be anticipated and the sick or preterm newborn may need to be transferred for definitive care to a neonatal intensive care unit after delivery. The care of the preterm newborn involves added considerations, above and beyond those of term newborns. These include consideration of survival prospects, the likelihood of long-term disability, the emotional needs of the baby and the parents, ethical considerations, resource implications, the appropriate use of cutting-edge technology and the need for critical evaluation of neonatal care practices. This facilitates data collection and allows for comparison between research studies. From this, generalisations can be made and information can be provided to families. He is called upon to play the part of a newborn infant with the personalia of a fetus. He is admirably fitted to continue living in the uterus, but is ill provided to meet the exigencies of an extra-uterine existence. He is suddenly forced Chapter 75 the Preterm Neonate and Perinatal Transport into surroundings of a kind which impose upon him urgent calls to which he is little able to respond. His tissues have not had time to mature, and he is not ready for so complete a change in environment. However, where these data are not available, or may be inaccurate, assessment of gestational age of the newborn can be made by physical examination. These are not necessarily pathological, but reflect particular stages of fetal development at given gestations. The area covered by deep creases on the sole of the foot extends during gestation, from toes to heel. In the very preterm newborn, the nipple is barely visible and the areola non-existent. Only by term have the labia majora developed to cover the labia minora and clitoris. Coincident with testicular descent is the development of increased rugosity of the scrotum. The newer Ballard assessment similarly uses physical and neurological assessments to assist in assessing the degree of prematurity. Importantly, due to variation in genetic and physical characteristics of newborns, most methods have an accuracy of ± 2 weeks either side of estimated gestation. Different jurisdictions and state-based protocols exist around Australia to guide clinicians. Appropriate counselling of parents and close communication between paediatric and obstetric staff is required when there is the prospect of a newborn being delivered on the cusp of viability. Hypoglycaemia should be routinely checked for on a regular basis until adequate caloric intake has been established and normoglycaemia has been documented. Blood sugar level may be measured in the nursery using commercial blood glucose test strips, but laboratory estimation is much more accurate. Definitions of hypoglycaemia vary, but since there is evidence that blood sugar levels at or below 2. In the mild case, an increase in feed volume may be sufficient if feeding has already been established. If the hypoglycaemia is more profound or persistent, an intravenous infusion of 10% dextrose should be commenced. Phototherapy is commenced in the very preterm infant at lower levels than those shown for mature newborns. This store is largely accumulated during the last 2 months of gestation and may be deficient in the preterm infant. Newborns weighing < 2000 g at birth are often nursed in an incubator set at the appropriate temperature (thus providing a neutral thermal zone and minimising energy expended on thermoregulation). Heat loss by evaporation is high due to the large insensible water loss, especially in extreme prematurity. This is followed by a proliferative phase of growth of abnormal new vessels from the retina into the vitreous humour. In severe cases, haemorrhage and oedema ensue and in the resulting organisation, fibrous scarring and retinal detachment may occur. The incidence of the disease is minimised by careful monitoring of blood oxygen levels and avoidance of periods of hyperoxaemia. All preterm newborns that require oxygen therapy must have non-invasive oxygen monitoring. As described in Chapter 70, if FiO2 is > 40%, then specialist tertiary care is often required to ensure adequate balance of oxygenation and ventilation is achieved. In established disease, retinal detachment may be prevented by the use of cryoor laser therapy to the retina. The germinal matrix, situated inferolaterally to the lateral ventricles, is the site of formation of the cortical neuronal cells. Haemorrhage in this area may result if there are major perturbations in blood pressure and cerebral blood flow. In the majority, the haemorrhage is localised and no long-term neurological sequelae result. Haemorrhage into the lateral ventricles may result in impaired drainage and resorption of cerebrospinal fluid, leading to obstructive hydrocephalus, which may require surgical treatment. The cerebral vasculature undergoes a gradual change in mid-gestation from supplying the brain parenchyma via penetrating cortical arteries to supply being via the basal cerebral arteries as in the mature brain. A catheter has been placed via an umbilical artery into his aorta to enable systemic blood pressure to be recorded and blood samples to be obtained painlessly for monitoring his biochemical and blood gas status. He is receiving a blood transfusion and his other intravenous infusion is to supply fluids, calories and electrolytes. Because of severe respiratory distress syndrome, his breathing is being assisted by a mechanical ventilator. To maintain his blood oxygen level at appropriate levels, oxygen saturation is being continuously measured. Apnoea is often associated with bradycardia and the lower the gestational age, the more common the condition. If the newborn is otherwise well, and apnoea is not the presenting sign of sepsis or intraventricular haemorrhage, it is likely to be due to the immaturity of the brainstem centres responsible for the automatic regulation of breathing. The ultimate treatment of extreme apnoea of prematurity (recurrent, prolonged or associated with marked bradycardia) is ventilatory (invasive or non-invasive) support of the immature respiratory system. Radiographic features are characteristic: gas is present in the bowel wall and may be visible in the portal venous system. Treatment comprises active resuscitation with the provision of ventilatory support, as well as cardiovascular support (inotropes, intravenous fluid resuscitation). Sequelae include bowel perforation in the acute stage, stricture and, later, short-bowel syndrome. The mortality rate depends on the severity of the disease, but can be as high as 20% in severe cases, especially in extreme prematurity. A Skin-to-skin contact between infant and parent (kangaroo care) promotes bonding. B Mother giving her baby expressed breastmilk (in syringe) via nasogastric tube, allowing close eye and skin contact between mother and baby. A Grade 1: Sagittal view showing a haemorrhage, subependymal in site which does not extend into the lateral ventricle (V). B Grade 2: the haemorrhage is more extensive: there is blood in the ventricle which, however, is not distended with blood. D Grade 4: Coronal view showing a haemorrhage which has involved a large area of the periventricular matter as well as filing the ventricle. After birth, the ductus must close or cardiovascular problems of left ventricular volume overload will develop. Under normal circumstances, the smooth muscle in the ductal wall constricts under the influence of the marked increase in the partial pressure of oxygen that occurs with the establishment 686 of respiration and the local production of prostaglandin F2 alpha. Immaturity of the ductal smooth muscle and a reduced ability to produce local prostaglandins are the reasons why patency of the ductus arteriosus is common in preterm newborns. After delivery, the pulmonary vascular resistance falls mainly as the result of the increase in PaO2. The pressure in the pulmonary artery rapidly becomes lower than the arterial pressure in the systemic circulation. If the ductus arteriosus remains patent, the left Chapter 75 the Preterm Neonate and Perinatal Transport ventricle pumps to both the systemic circulation and, via the ductus arteriosus, to the pulmonary circulation. In this case, the increased volume load on the left ventricle leads to left ventricular failure. The clinical presentation of patent ductus arteriosus is with respiratory distress, often on days 4 to 7, just as the newborn is recovering from respiratory distress syndrome. There is a widened pulse pressure causing a bounding pulse and often a continuous murmur. Drug treatment is often reserved for premature infants that have been unable to be weaned off mechanical ventilation. Key factors that have significantly contributed to the improved survival are the use of antenatal corticosteroids to enhance lung maturity when preterm birth is thought to be imminent, as well as the use of exogenous lung surfactant. Australia-wide data shows that over 60% of 24-week premature infants survive to discharge. Gas has penetrated through the intestinal wall into the portal venous system and can be seen throughout the liver. By comparison, severe disability can still occur in up to 5% of full-term neonates. For example, up to 50% of extremely premature neonates who survived until discharge, when assessed at 30 months of age, may have minimal to no disability. Additionally, the functional ability of premature infants (when assessed at infant and/or school age) is an important neurodevelopmental outcome. While 83% of extremely low birth weight infants can walk independently by 22 months of age, more subtle deficits (such as poorer participation in sports in teenage years) can appear later in life. Even when this allowance is made, preterm infants are slightly lighter and shorter than term infants. By this time, the scaphocephaly-a feature of many very preterm infants-has largely resolved. Follow-up and post-discharge care Preterm newborns may go home with continuing problems of feeding difficulties, oxygen dependence, ongoing surgical problems (such as inguinal hernias) or neurodevelopmental issues. Because of this, many units organise a home visiting service staffed by experienced neonatal intensive care unit and/or midwifery staff. Close multidisciplinary follow-up of newborns < 1500 g is desirable because of the increased risk of disability. Some disability is subtle and may first present in the school years with difficulty in accomplishing the tasks demanded in such an environment. Gestational age at birth (weeks) 24 to 25 26 to 29 Rate of intellectual disability (%) 30­50 10­30 Panel A: Male infants 1. Source: Reproduced from Actuarial day-by-day survival rates of preterm infants admitted to neonatal intensive care in New South Wales and the Australian Capital Territory.

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