OPHTHALMIA NEONATRUM

Definition
Ophthalmia neonatrum is a notifiable condition defined as any purulent discharge
from the eyes of an infant within 21 days of birth or any inflammation that occurs in the eyes
of an infant within 21 days of birth that is accompanied by discharges.
Etiology
The condition is associated with the mother during sexual transmitted disease such
as gonorrhoea, Chlamydia in pregnancy or other sexuality transmitted diseases. The
causative organism from vaginal canal such as staphylococcus aureus, streptococcus
pneumonae, haemophilus influenza, E. Coli, Klebsiella pseudomonas, Chlamydia
trachomatis and Neisseria gonorrhoea.
Diagnosis
Swab must be taken for culture and sensitivity test for causative organism for neisseria
gonorrhoea, gram negative intracellular diplococcic must be observed.
Onset & Presentation Etiology Conjunctival scraping
Within 24 hours Chemical Silver nitrate No organism seen
Bilateral mild lid oedema Only a few
with watery discharge polymorphonuclear
leukocytes may be seen

2-4 days Neisseria Gonorrhoeal Gram -ve intracellular

Severe swelling diaplococci
Purulent discharge may
produce keratitis corneal
ulcer & perforation

4-10 days Chlamydia Giemsa stain for

Variable severety of lid cytoplasmic inclusion
swelling with serious or bodies, positive direct
purulent discharge immunoflouroscent assay

4-7 days Other bacteria Gram stain +ve for the

Purulent discharge
6 days to 2 weeks
Often unilateral serious
discharge with keratitis
bacteria
Herpis simplex Gram stain for multicellualr
giant cells, papanicolous
stain, intranuclear inclusion
bodies

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Specific Treatment
1. Chemical conjunctivitis - spontaneous resolution in (2-3) days.
2. Gonococcal infection: Topical erythromycin ointment and systemic 3 rd generation
cephalosporin is the treatment of choice. Intravenous penicillin G 50,000 units / kg /
day every 12 hours with 10,000 to 20,000 units / ml of crystalline penicillin eye drops
freshly prepared every day and administered every one hourly is an acceptable
alternatively.
3. Chlamydia conjunctivitis: Treatment with oral and topical erythromycin recommended.
Treatment should be continued for 2 weeks to prevent recurrence and secondary
Chlamydial pneumonitis.
4. Herpes simplex infection: Treatment with acyclovir ointment and oral acyclovir .
Prevention
1. Antenatal screening and detection of STD mother is very essential.
2. Care of the eye as soon as possible may prevent such type of diseases. Wipe or
clean with sterile cotton swabs in single stroke from inner canthus to outer canthus.
Local cleaning and irrigation of the eye with normal saline and application of
prophylaxis can protect the eye if an infant. In1818 Crede use 2 percentile silver nitrate
solution placed in the eye at birth. One percent tetracycline ointment was used, but
sometimes it is resistant to gonococci than 0.5 per cent erythromycin was used as
prophylaxis. After that it was observed 2.5 per cent Povidone iodine ophthalmic solution has
proven to be very effective in prophylaxis of ophthalmic neonatorum. The accept from of
prophylaxis are
1. Crede’s method - 1 per cent silver nitrate.
2. 0.5 percent erythromycin ointment.
3. 1 percent tetracycline ointment.
4. 2.5 percent Povidone iodine.
Conclusion
Eye is a very valuable part of human life. Simple negligence may pull on infant to
darkness as a community health nurse we should found out the risk cases B screening for
S.T.D. is very essential eye care during delivery in also an essential part.

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CONGENITAL ABNORMALITIES
Definition
Congenital abnormalities are the diseases or any defects in the form of structure or
function which is present before birth. The identifiable defects can be categorised in four
ways.
Causal Classification
1. Chromosome and gene abnormalities.
2. Teratogenic causes
3. Multifactorial causes
4. Unknown cause.
Other Classification
1. Major versus minor abnormalities
2. Isolated versus multiple abnormalities
Etiology
Malformed live birth
Etiology
percentage
Genetic disorder :

Cytogenic factor 5

Mendallion inheritance 15-20

Unknown factor (Palygenic, Multifactorial, Synergium, 65-70

Spontanous errors of development)

Environmental (exposure of the embryos)

Maternal infections 3

Maternal disease state with smoking & nutritional 4

problems

Problems of constant 2

Drugs, chemical, irradiation hyperthermia 1

Genetic Disorders
Genetic disorder can be classified under one of the three categories (a)
chromosomal disorder, (b) Medallion or monogenic disorder, (c) complex disease traits.
Each of these present different problems with respect to pathogens prevention diagnosis

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genetic counsel and treatment. The frequency of genetic disorders vary i.e. 6-8 per cent of
disease are due to single gene defects 0.4-2.5 percent to chromosomal abnormalities and
another 22-31 present are consider to be gene influenced.
Teratogenic cause
A teratogen is any agent that raises to incidence of congenital abnormalities. These
include prescribed drugs (e.g. anticonvulsant, anticoagulants, preparation containing large
quantity of Vitamin A which are prescribed for acne) drug used in substance about
environmental factors such as radiation and chemicals infective agents (rubella, cytomegali
virus) and maternal disease conditions (e.g. diabetes). This factor also consider that
according to the gestational age, time of exposure, length of exposure toxicity of
teratogenes the malformation will vary.
Multifactorial
These are due to a genetic defect in addition to one or more teratogenic infect in
addition to one or more teratogenic influences.
Unknown Cause
In spite of growing body of knowledge the specific cause around 70% of
abnormalities remain unspecified.
Gastrointestinal Malformation
i) Gastroschisis - is a paramedian defect of the abdominal wall with extrusion of
bowel that is not covered by peritoneum making vulnerable to infection injury. The
size of the defect will determine, weather primary closure is possible or whether a
temporary side made from synthetic material is necessary until the abdominal cavity
is able to caution the abdominal organ.
ii) Exomphalus : It is a defect in which bowel or other viscera produce through
umbilical. Surgical correction is needed like gastroschisis.
3. Atresias
i) Oesophageal atresia occurs when there is incomplete civilisation of the oesophagus
in early intrauterine development. It is commonly associated with trachea esophagial fistula.
This can be suspended in the presence of maternal polyhydramnious. At birth the baby has
copious amount of mucus coming form the mouth. Early detection is essential. The baby
should feel by gastroctomy tube. But oral stimuli should encourage.

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Duodenal Atresia
This can be diagnosed by persistence vomiting at 24-36 hours. The baby’s vomits
some time continuous unless the obstruction is on proximal end. Rectal atresia and
imperforated anus.
Rectal atresia and imperforated anus
Imperforated anus may notify early at birth but rectal atresia only noted if baby fail to
pass meconium in first 24 hours after delivery. X-ray can confirm the condition. Other
conditions in which the baby fails to pass stool in first 24 hours pregnancy are (1)
Malrotation / volvulus, (2) Meconium ileus, (3) Hirschsprung’s diseases.
Pyloric Stenosis
It arises form genetic defects that cause hypertrophy of the muscle of the pyloric
sphincter. The symptom is projectile vomiting usually at around 6 weeks of age. Boys are
mainly affected.
Cleft LIP and Palate
Cleft lip may be unilateral or bilateral cleft lip is very often accompanied by cleft
palate. In initial examination of the baby the palate be examined by means of good light
source if the defects limited to unilateral cleft lip breast feeding should encouraged. Where
there is additional problem of cleft palate arranging the baby to be fitted within orthodontic
plate may facilitate breast feeding but this obviously does not afford the same stimulus as
nipple to palate contact. Middle ear infection is more. Expressed breast milk may be given
by cup and spoon. Surgery 3-4 months of age of cleft lip because cleft lip occurs as a
feature of other medical condition which can not detect early. Palate closure at 12-15
month of age because delay allow to sufficient growth of palate which result reducing size
of the defect.
Abnormalities Relating to Respiration
Diaphragmatic hernia: This abnormality consists a defect in the diaphragm that
allows herniation of abdominal content into the thoracic cavity. The extent to which long
development is compromised as a result depends on the size of the defect and the
gestation age of which herniation first occurred. This condition may be diagnosed
antenatally by ultrasound. At birth the condition maybe suspected if the baby is cyanosed
and difficulty is experienced in resuscitation. Since majority of such defect left sided heart
sound will displaced on right chest X-ray confirm diagnosis. Surgical repair is necessary.

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Choanal Atresia
Choanal atresia described a unilateral or bilateral narrowing of the nasal passage
with a web of tissue or bone occluding nasopharynx. Tachepnoea and dyspnoea are
cardinal features. The baby must be mouth breath feeding is difficult and nasal catheter can
not passed into the pharynx. Incidence cell 1: 800. Surgical correction is required.
Laryngeal Strider
This is a noise made by the baby usually on inspiration and exacerbated by crying.
Most commonly the cause is laryngomalacia which is due to laxity of the laryngeal cartilage.
Although sound is distressing the baby generally is not at all upset. If however, the strider
is accompanied by sig not dysponea or feeding problem further investigational such as
bronchoscopy or laryngoscopy would become necessary to rule out a more sinister cause.
Congenital Cardiac Defect
Approximately 90% of cardiac defect can not be attributed a single cause.
Chromosomal and genetic foetus account for 8% and further 2% reckoned to be caused by
teratogen. The critical period of exposure to teratogen in respect of embryological
development of cardiac tissue is from 3rd to the 6th week.
Prenatal Detection
An increasing number of cardiac problems are being identified by means of detailed
ultrasound scanning. However detection of many defects is still dependent often accurate
observation and examination during neonatal period.
Postnatal Recognition
Clinical babies with cardiac anomalies can be divided into two groups those with
central cyanosis and those without cyanosis.
Cardiac Defects presenting Cyanosis
Defects included in this group are in under of frequency.
 Transportation of the great vessels (aorta rises from right ventricle and pulmonary artery
from left ventricle).
 Pulmonary atresia
 Fallot’s tetralogy (pulmonary stenosis, enlargement of right ventricles and ventricular
septal defects).
 Tricuspid atresia
Acyanotic Cardiac defect
Patent ductus arteriosus

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Ventricular or arterial septal defects
Coarctation of the aorta (congenital narrowing of a short segment of the aorta.
Hypoplastic left heart syndrome.
In coarctation of aorta the must common site as just beyond the origin of left
subclavian artery from aorta. This results in high blood pressure in the upper part of the
body (eg. Arms) and low blood pressure in leg.
Symptoms
Tachypnoea, tachycardia, incipient cyanosis specially following execration of crying
or feeding.
Treatment: Especially surgical
Central Nervous System
Investigation of folic acid supplement prior to conception and during early stage of
pregnancy has helped to prevent such abnormality.
Anencephaly
Absence of fore brain and vault of the skull.
Spina bifida
a) Spina bifida aperta
Result from failure of fusion of the vertebral column. There is no skin covering the
defect which allows the protusion of the meningus. The menigeal membrane may be flat or
appear as a membranous sac with or without CSF. This is meningocele.
Meningomyelocyle involves spinal cord when the defect is on the base of the skull known
as encephalocele which contain various amount of brain tissue. Immediate management
involves covering over lesion with an non-adherent drilling baby should be very carefully.
Surgical correction may be done.
Spina bifida occults
Minor disorder where vertebra is bifid. No spinal cord involvement A tuft of hair or
sinus may be noted during examination of baby.
Hydrocephalus
Hydrocephalus arises form a blockage in the circulation and absorption of C.S.F.
which is produced from the choroid plexuses within the lateral ventricle of the brain. The
large lateral ventricle increase in size and eventually compressed the surrounding brain
tissue. The risk of cerebral impairment may be minimised by insertion of
ventriculoperitoneal sunt.

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Microcephally
This is where the ocipitofrontal circumference is more than two below normal for
gestational age. This small head is due to intrauterine infection like rubella.
Musculoskeletal System
1) Polydactyly (extradigits)
2) Syndactyly (fusion of digit)
These are genetically inhabited condition.
Limb reduction Anomalies
Cause :
1) Amniotic band syndrome (amino ruptured and warp around a developing limb
causing strangulation and necrosis.
2) Teratogens factors
Treatment
Prosthesis, transferring toes hands etc.
Talipes
Talipes equinovarus (club foot) is the descriptive term for a deformity of foot where
the ankle is bend down wands and front par is turned in wands. Talipes calcaneivalgus is
described the opposite position where the foot is dorsiflexed. These condition occur when
intra uterine space has been at a premium ex. Multiple pregnancy, macrosomic fetus or
oligohydrominos. Correction is splints otherwise surgical correlation.
Developmental Hip Dysplasia
It is more commonly found where there is history of oligohydrominous or breech
presentation. The hip may be dislocated or dislocatable, management include a splint or
harness such as pavlik harness applied which will keep the hips in a flowed and abducted
position of about 60%. The splint should not be removed during napkin changing and
bathing parent should learn bow to handle the baby and providing care.
Achondroplasia
It is an autosomial dominate condition where the baby is generally small with
disproportionately long head and short limbs. These babies may develop lordosis in later
life.
Abnormalities in Skin
Capillary malformations
These are due to defects in the dermal capillaries commonly observed stork marks
and they are small and will fade. No treatment is necessary.

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Capillary haemaniomata : Not usually noticeable at birth but appeared as red, no treatment
is required for these.
Pigmented Naevi : These are brown, some times hairy marks on the skin vary in side may
be flat or raised. A percentage of this type may become malignant. Surgical excision may
required to pre-empt this.
Genitourinary System
Posterior Uretjral valve
In boys and prevalence of valves in the posterior urethra prevent normal out flow of
urine as a result bladder distends causing hydronephrosis. Prenatal diagnosis and
intervention by intrauterine fetal bladder catheterisation is possible failing this early
diagnosis in the neoantal period is cleanly imported but several renal damage may already
have been sustained.
Polycystic kidneys
Delivery is difficult due to increased abdominal girth. Prognosis poor renal failure
occur after birth.
Hypospadias
Urethral orifice in the dorsal surface of the point which can be cured by surgery. In
this condition the penis is sharp and bent and broken is present only the dorsal site of the
penis.
Cryptochidism
Undescended testis the testis may found in inguinal pouch. Some times manipulated
some times manipulation cause malformation. So after the child became 2 years
orchidipexy may be done.
Ambiguous genitalia
Examination of the baby may reveal any following i.e. a small hypoplastic penis,
chordee, bifid scrotum, undescended testis or enlarged clitoris, in completely separated or
poorly differentiated labia. There are a number of causes of ambiguous genitalia all which
need expert clarification.
COMMONLY OCCURRING SYNDROME
Trisomy 21 (down syndrome).
The features are described in 1866 by John Down. His description included the
features as widely set and obliquely slanted eyes, small nose and thick rough tongue.
Other sing small head with flat occipital, squat broad hands with incurring little finger wide
space between thumb and little finger, a single palmer crease, brusfield spot in eyes and

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generalised hypertonea not all manifestation need to present. Any of them can occur alone.
Babies born with down syndrome have an incidence of cardiac anomalies leukaemia and
hypothyroidism. IQ is below average at 40-80. If any symptoms found further investigation
may needed.
Trisomy 18 : Incidence 1:5000. An extra 18 th chromosomal is responsible for this. The life
span of there children is short must of die within 1 st year. They have a short head with
flattened forehead, a reading chin to cleft palate low set ears, short sternus fingers are
overlap. In these babies malformation of the cardiovascular and GI system is common.
Trisomy 13 (Patau syndrome)
The extra copy of 13th Chromosomal leads to multiple abnormalities like
microcephalic, facial abnormalities, brain and cardiac abnormalities. These children having
short life any 5% live beyond 3 years.
Pottor Syndrome
This collection features of on still horn infant which first described by potter in 1946.
It is due to compressive oligohydrominous or severe hypoplasia. The baby face will have
flattened appear lowest ears, antimangaloid slant to the eyes and a beaked nose. They
are severely asphyxiated at birth because they have lung hypoplasia.
Turner Syndrome
This is a monosomal condition only one sex chromosomal exists on X. The absent
chromosomal is indicated by O. The child is a girl with short webbed neck, widely spaced
nipples and oedematous feet. The genitalia tends to be underdeveloped. The internal
reproductive organ do not mature. This condition may not be diagnosed until puberty fails
to occur. Congenital cardiac defect may also be found mental development normal.
Klinifelter syndrome (XXY)
This is an abnormality affecting boys but it is normally diagnosed until pubertal
changes fails to occur.
Role of Nurse for Congenital Anomalies Families
Caring of mother good antenatal care and advice about tertatogenic factors which
may develop congenital anomalies is very essential. Early screening for any congenital
anomalies helps the parent to take a step whether they can continue pregnancy or not. The
exercising of effective counselling and communication skulls is valuable in helping the
family to adjust and facilitating appropriate lines of support.

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Conclusion
Looking forward to the arrival of a healthy baby is every prospective parents drawn.
Sadly far some, this drawn is a battered when the presence of some form of abnormality is
recognised prenatally, at birth or in the neonatal period. It is therefore likely that every
practising midwife will at some time be confronted with the challenge of providing
appropriate care and support for such babies and families.
Bibliography
1. Diane M. Fraser, Margaret A Copper (2993). “ Myles Textbook for Midwives’,
Fourteenth Edition, Elsevier Science Limited Publication, Pp, 377,378,8 883, 841-861.
2. Dipak K. Guha (2005). Guha’s Neonatology”, 3rd Edition, Japyee Brother Publication
(New Delhi), Pp. 1141, 325-350, 952-996.
3. Marilyn .J .Hockenberry (2005) “Essentials paediatric nursing “7th edition, Mosby
publication, Pp. 1164-1204.
4. Gupte Suraj (2005) “ Short text book of Paediatrics“ 10th edition , Jaypee Brothers
publication , Pp. 285-300,600-700

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 INDEX

Sl.No CONTENT PAGE NO

01 Ophthalmic Neonatrum 1

02 Congenital Anomalies 3

03 Gatro Intestinal malformation 4

04 Anomalies related respiration 5

05 Congenital cardiac defect 6

06 Central Nervous System 7

07 Musculoskeletal system 8

08 Abnormalities 8

09 Genito Urinary system 9

10 Commonly occurring syndrome 9

11 Role of nurse for congenital anomalies families 10

12 Conclusion 11

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