Chapter 3. Common postnatal problems
This chapter aims to address the commoner problems that paediatricians are called to review on the postnatal ward. It is by no means an exhaustive list of the problems that may occur and a standard textbook of neonatology should be consulted for more detailed information.
QUESTIONS
1. The following are contraindications to the BCG vaccination. Choose two correct answers:
a. Prematurity
b. Down syndrome
c. Babies born to HIV positive mothers
d. Babies with chronic lung disease
e. Family history of egg allergy
f. Family history of inflammatory bowel disease
g. Babies being treated with dexamethasone for chronic lung disease.
2. You are called to delivery suite to speak to some parents that have refused to let their baby have vitamin K. The father says that it is unsafe and causes cancer. Mum wishes to breast feed.
a. What are you going to tell them?
b. You find out that mother is on anticonvulsant medication. Does that affect what you say?
After you have discussed this with the family, the father then points out that there is a family history of glucose-6-phosphate dehydrogenase deficiency.
3. A baby is noted to have a sacral dimple on the postnatal check. On further examination, the dimple is found to be 2 cm above the anus and there is a small erythematous patch over the spine.
a. Are there any investigations you would do?
b. Why?
4. A mother was started on treatment for TB 7 days before delivery and her sputum for AFB is negative. Her baby is asymptomatic on examination. What management would be appropriate for the baby? Give two answers.
a. Isolate the baby from the mother
b. Encourage bottle feeding
c. Treat with isoniazid, rifampicin and pyrazinamide
d. Treat with isoniazid and rifampicin
e. Treat with isoniazid
f. Encourage breast feeding
g. Vaccinate the baby with BCG at birth
h. Vaccinate the baby with isoniazid-resistant BCG at three months
i. Do nothing.
5. You are called to see a term baby who is now 28 hours old. The baby has not passed meconium. The parents want to take their baby home and are becoming quite agitated. How do you manage the situation? Choose the most appropriate action.
a. Send baby home
b. Send baby home with clinic review in one week
c. Arrange urgent surgical review
d. Arrange contrast studies
e. Arrange plain abdominal x-ray
f. Keep in for observation.
6. A baby is noted on routine postnatal check to have absent red reflexes. Which of the following diagnoses need to be considered?
a. Congenital hypoparathyroidism
b. Retinopathy of prematurity without plus disease
c. Congenital hyperparathyroidism
d. Hallermann–Streiff syndrome
e. Persistence of the tunica vasculosa lentis
f. Retinal haemorrhage
g. Retinoblastoma
h. Lowe syndrome
i. Congenital glaucoma
j. CHARGE syndrome.
7. On a routine review of a baby on the neonatal unit, you noticed the baby has purulent discharge from both eyes. The baby is 4 days old. What is the most likely organism to cause this? Choose the best answer.
8.
i. Which of the following are risk factors for developmental dysplasia of the hip?
a. Male
b. Transverse lie
c. Previous affected sibling
d. Polyhydramnios
e. Intra-uterine growth retardation
f. First-born child
g. Torticollis.
ii. A mother reports that she required some form of harness when she was a baby. There have been two previous children who have been normal. The hips appear stable on examination. What action would you take?
9. A mother is known to have thyroid disease but has normal thyroid function tests. One of your SHOs organises for the baby to come back for thyroid function tests at 4 days of age. The results of these are as follows:
| Free T4 | 80 pmol/L |
| Total T4 | 300 pmol/L |
| TSH | 2 mU/L |
What action would you take?
a. No action and discharge the child
b. Repeat the tests in 2 weeks time
c. Repeat the test in 2 days time
d. Refer to paediatric endocrinology clinic
e. None of the above.
10. A baby is noted on postnatal check to have an undescended testicle (UDT). Which of the following statements are correct?
a. The majority of UDT will have descended successfully by 12 months of age
b. If still not descended at 12 months, 75% will descend by 36 months of age
c. Only a small minority are palpable
d. Early orchidopexy will preserve fertility in the majority
e. UDT requires orchidopexy to reduce the incidence of malignant change
f. UDT requires urgent review because of the risk of torsion
g. UDT usually responds well to hormonal therapy
h. UDT may be associated with urinary tract abnormalities.
12. The mother of a newborn baby girl informs you that her two previous babies, both boys, had pyloric stenosis, as did she. Which of the following statements are correct?
a. The chance of pyloric stenosis in this baby is no different to that for a baby with no family history
b. As this is a female infant, pyloric stenosis is less likely compared to a male infant
c. A test feed and abdominal ultrasound should be performed
d. Prophylactic pyloromyotomy is indicated
e. The baby should be fed normally
f. Treatment with anticholinergic drugs is now widely accepted as first-line management
g. In up to 7% of cases of pyloric stenosis there may be associated malformations.
13. A term baby is two weeks old, breast fed and thriving, with normal urine and stool colour. Examination is unremarkable but she is noticed to be moderately jaundiced. The bilirubin is 180 μmol/L, conjugated 10. Which of the following investigations should you carry out as part of your initial assessment?
a. Liver USS
b. HIDA scan
c. Haemoglobin
d. DCT
e. Urinalysis
f. Clinitest
g. Thyroid function tests
h. Red cell fragility
i. Blood cultures
j. UDPGT
k. Gene screen for Gilbert’s.
14. How would your approach differ if the conjugated bilirubin had been 40 μmol /L but with normal urine and stool colour?
15. A liver ultrasound scan suggests that bile ducts are present, and shows what appears to be an abnormally large gall bladder. What is the most likely diagnosis? Choose one answer.
a. Atypical biliary atresia
b. Duodenal web with biliary reflux
c. Normal variant
d. Inspissated bile
e. Diverticulum of the bile duct
f. Cystic dilatation of the common bile duct
g. Choledochocele.
16. A liver ultrasound examination is equivocal. A gall bladder is seen and the report states that the bile ducts were not clearly visualised but could have been obscured by the gall bladder. Which of the following is most appropriate? Choose one answer.
17. A baby is born to a mother who was noted to have significant anti-D levels during pregnancy. A cord blood sample was sent and you have just been informed that the cord bilirubin level was 180 μmol/L. The baby is now 4 hours old. You send a repeat blood sample for group and crossmatch, and Coombs’ test, and commence phototherapy. The following results are obtained within 2 hours:
| Bilirubin | 240 μmol/L |
| Hb | 12.5 g/dL (fragments seen suggestive of severe haemolysis) |
| Group A Rh positive | |
| Coombs strongly positive | |
Blood bank informs you that there are very abnormal antibodies in addition to Rhesus antibodies, and there may well be a delay of a few hours until blood is available.
Which of the following should be considered?
a. Encourage frequent breast feeding
b. Immunoglobulin infusion
c. Phenobarbitone
d. Albumin
e. High intensity daylight fluorescent bulb phototherapy
f. Intravenous fluids
g. Metalloporphyrin treatment
h. Withhold vitamin K to reduce risk of added oxidative damage
i. Liver USS to exclude biliary atresia.
18. A midwife calls you to review a baby with the following. The parents are extremely anxious about the baby? What are you going to tell them?
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| Figure 3.1. |
ANSWER 1
a. Prematurity is not a contraindication for immunisation. It is commonly thought that babies under a certain weight should not be immunised – this is also not the case.
b. Down syndrome (or any stable neurological condition) is not a contraindication for immunisation. 1
c. Babies born to mothers with HIV must not be given BCG vaccine until the baby’s serology is confirmed to be negative. There have been reports of dissemination of BCG in HIV positive individuals. 1
d. Babies with chronic lung disease who are not receiving steroid treatment can receive the BCG vaccination. 1
e. A family history of egg allergy is not a contraindication for BCG vaccination. Egg allergy is only a problem with yellow fever and influenza vaccines. There is increasing evidence that MMR vaccine can be given even to children with a history of previous anaphylaxis after egg ingestion. 1
f. This is not contraindicated. There was previous speculation linking the MMR vaccine with inflammatory bowel disease but this evidence is not convincing. 1
g. Babies who are receiving immunosuppressive doses of steroids, greater than 300 μg/kg/day of dexamethasone for at least one week (which is equivalent to 2 mg/kg/day prednisolone), should not receive live vaccines. Administration of live vaccines should be postponed for at least 3 months after immunosuppressive treatment has stopped. 1
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