ophthalmianeonatrum

neonatal conjunctivitis

1. OPHTALMIA NEONATORUM Introduction Definition - inflammation of the conjunctiva in the first 28 days of life . Also known as Neonatal Conjunctivitis . Neonatal conjunctivitis , also known as ophthalmia neonatorum , is a form of conjunctivitis and a type of neonatal infection contracted by newborns during delivery. The baby's eyes are contaminated during passage through the birth canal from a mother infected with either Neisseria gonorrhoeae or Chlamydia trachomatis

2. Epidemiology Before introduction of silver nitrate eye drops in the late 19th century, approximately 10% to 15% of newborns developed bacterial conjunctivitis. Current incidence varies by the availability of obstetric care. Annual rates of gonococcal and chlamydial conjunctivitis per 1,000 live births are approximately 0.3 and 5, respectively, in the United States but are ten times greater in parts of Africa & india . The risk of corneal complications from ophthalmia neonatorum is higher among the poor. Between 1,000 and 4,000 infants are blinded each year.

3. Predisposing Factors Organisms in vagina shed during delivery Premature rupture of membranes Long delivery Few tears and low levels of IgA Trauma to epithelial barrier Prophylaxis (silver nitrate)

4. Types… Aseptic – Chemical conjunctivitis mostly Silver nitrate - prophylaxis of infectious conjunctivitis - C rede’s method of prophylaxis not as common anymore because of the use of erythromycin ointment. Septic- Bacterial, chlamydial (the most common cause), and viral infections are major causes Acquired by passage through birth canal

5. Etiology Chemical or Microbial Chemical Silver nitrate surface-active chemical, facilitating agglutinate gonococci and inactivating them . toxic to the conjunctiva, potentially causing a sterile neonatal conjunctivitis .

6. Etiology … Microbial Chlamydia trachomatis the most common infectious cause 4-10% pregnant women infected Infants whose mothers have untreated chlamydial infections antepartum have a 30% to 40% chance of developing chlamydial neonatal conjunctivitis postpartum. reservoir- maternal cervix or urethra

7. Etiology … Neisseria gonorrhea have the ability to penetrate intact epithelial cells, and once inside the cell, they divide rapidly. the most dangerous and virulent infectious cause must be absolutely excluded in every case serious consequences

8. Etiology … Other bacteria Staphylococcus aureus , Streptococcus pneumoniae , Streptococcus viridans , and Staphylococcus epidermidis . Escherichia coli, Klebsiella pneumoniae , Serratia marcescens , and Proteus, Enterobacter , and Pseudomonas species

9. Clinical Difficult to know cause on clinical ground only Significant overlap in presentation Main findings are erythema , chemosis & purulent eye discharge Therefore Lab studies are Important

10. Clinical… Incubation Period Chemical conjunctivitis (silver nitrate)- 1st day of life- disappear spontaneously in 2-4 days Gonococcal - 3-5 days or later Chlamydial- 5-14 days Other bacteria- longer Herpetic- within 2wks

11. Clinical… Chlamydial From Mild hyperemia with scant mucoid discharge Eyelid swelling, chemosis and pseudo membrane formation unilateral or bilateral watery discharge which may become more copious and purulent later Blindness-rare and slower to develop-b/s of eyelid scarring and pannus (non suppurating inflamed lymph gland ) Pneumonitis, pharyngeal and rectal colonization

12. Treatment Prophylaxis Antenatal - thorough care of mother and treatment of genital infections when suspected. Cesarean Delivery Natal - Topical 0.5% silver nitrate, 1% tetracycline for gonococcal infection

13. Treatment … Treatment prior to laboratory results Topical erythromycin ointment and IV or IM third-generation cephalosporin (ceftriaxone 30-50mg/kg/d IV or IM. Max 125mg)

14. Treatment … Gonococcal Conjunctivitis Topical administration of broad-spectrum antibiotics (gentamicin eyedrops every hour) + Systemic penicillin (penicillin G iv 2 million IU daily) OR A single dose of ceftriaxone (75-100 mg/kg/day IV or IM QID for 7 days) is an alternative treatment.

15. Treatment … Chlamydial Conjunctivitis Topical erythromycin eyedrops (5x/day) + Oral erythromycin (50 mg/kg/d divided QID) Since the efficacy of systemic erythromycin therapy is approximately 80%, a second course sometimes is required.

16. Neonatal Jaundice ( Hyperbilirubinemia ) Definition: Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is characterized by jaundice, a yellowish discoloration of the skin, sclerae , mucous membranes and nails. Neonatal Jaundice(also called Newborn jaundice) is a condition marked by high levels of bilirubin in the blood.

17. NJ - 19

18. Neonatal Jaundice Visible form of bilirubinemia Newborn skin >5 mg / dl Occurs in 60% of term and 80% of preterm neonates However, significant jaundice occurs in 6 % of term babies 6-10% require phototherapy/ other therapeutic options.

19. Clinical assessment of jaundice (Kramer’s staging) Area of body Bilirubin levels mg/dl (*17=umol) Face Zone-1: 4-6 Upper trunk Zone-2 : 6-8 Lower trunk & thighs Arms and lower legs Zone-3: 8-12 Palms & soles Zone-4 :12-14 Zone-5 :>15

20. Physiological jaundice Characteristics Appears after 24-72 hours Maximum intensity by 3th-5th day in term & 7th day in preterm Serum level less than 15 mg / dl Clinically not detectable after 14 days Disappears without any treatment

21. Pathological jaundice Appears within 24 hours of age Increase of bilirubin > 5 mg / dl / day Serum bilirubin > 15 mg / dl Jaundice persisting after 14 days Stool clay / white colored and urine staining clothes yellow Direct bilirubin > 2 mg / dl

22. Causes of jaundice Appearing within 24 hours of age Hemolytic disease of NB : Rh , ABO Infections: TORCH, malaria, bacterial G6PD deficiency

23. Causes of jaundice Appearing between 24-72 hours of life Physiological Sepsis Polycythemia Intraventricular hemorrhage Increased entero -hepatic circulation

24. Causes of jaundice After 72 hours of age Sepsis Cephalhaematoma Neonatal hepatitis Extra-hepatic biliary atresia Breast milk jaundice Metabolic disorders (G6PD).

25. Risk factors for jaundice JAUNDICE J - jaundice within first 24 hrs of life A - a sibling who was jaundiced as neonate U - unrecognized hemolysis N – non-optimal sucking/nursing D - deficiency of G6PD I - infection C – cephalhematoma /bruising E - East Asian/North Indian

26. Therapeutic Management Purposes : reduce level of serum bilirubin and prevent bilirubin toxicity Prevention of hyperbilirubinemia : early feeds, adequate hydration Reduction of bilirubin levels: phototherapy, exchange transfusion, Drugs Use of Phenobarbital promote liver enzymes and protein synthesis.

27. Babies under phototherapy Baby under conventional phototherapy Baby under triple unit intense phototherapy

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