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Atlas of Neonatal Pathology
Marta Ježová, Josef Feit
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+ Introduction
+ Using this atlas
+ Conditions of using this atlas
+ Technical notes
+ Hardware
+ Software
+ How to use the atlas
+ Navigating through the text pages
+ Controlling the pictures
+ Logos and labels
+ What will you need to use the atlas
+ Bugs, problems
+ Netscape
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+ Some other Internet resources concerning dermatopathology and pathology
+ Support
+ Support
+ Neonatal pathology
+ Basic terms and classification of newborn infants
+ The Apgar score
+ Classification of newborn infants by weight and gestation
+ Pathology of gestation length
+ Prematurity
+ Postmaturity (Clifford syndrome)
+ Growth and developement
+ Intrauterine growth retardation (IUGR), small for gestational age infant (SGA)
+ Large for gestational age infant (LGA)
+ Physical maturity
+ Pathology of prematurity
+ Gross appearance of premature infant
+ Difficulties in maintaining homeostasis
+ Thermoregulation
+ Hypoglycemia
+ Hyperbilirubinemia
+ Fluids and electrolytes
+ Apnea of prematurity
+ Anemia of prematurity
+ Hyaline membrane disease (HMD)
+ Necrotizing enterocolitis (NEC)
+ Intraventricular hemorrhage (IVH)
+ Periventricular leukomalacia (PVL)
+ Patent ductus arteriosus (PDA)
+ Iatrogenic diseases and damage
+ Respiratory system
+ Injuries caused by endotracheal intubation
+ Pulmonary air leak
+ Bronchopulmonary dysplasia (BPD)
+ Retinopathy of prematurity (ROP)
+ Cardiovascular system
+ Total parenteral nutrition associated hepatic damage
+ Infections
+ Viability, survivability and long term sequelae of prematurity
+ Viability
+ Survivability in prematurity
+ Severe long term sequelae in babies born prematurely
+ Birth asphyxia
+ Hypoxic-ischemic encephalopathy (HIE)
+ Meconium aspiration syndrome (MAS)
+ Persistent pulmonary hypertension of the newborn (persistent fetal circulation)
+ Birth trauma
+ Extracranial lesions
+ Soft tissus injuries
+ Intraabdominal injuries
+ Peripheral and cranial nerve injuries
+ Bone injuries
+ Cranial trauma
+ Perinatal infection
+ Intrauterine infections (TORCH group)
+ Sepsis neonatorum
+ Blenorrhea neonatorum
+ HIV infection
+ Stillbirth and perinatal mortality
+ Stillbirth
+ Perinatal mortality
+ Neonatal pathology nonrelated to prematurity, birth asphyxia or infection
+ Congenital anomalies in liveborn infants
+ Kernicterus
+ Hemorrhagic disease of the newborn
+ Spontenous gastric perforation in a neonate
Necrotizing enterocolitis (NEC)
Introduction

NEC is more prevalent in premature infants but can be also observed in near-term or term infants. In preterm infants the incidence is inversely related to gestational age.

Etiology

The etiology is controversial, several factors have been suggested as being important:

  • intestinal ischemia
  • enteral feeding
  • abnormal intestinal flora, bacterial overgrowth
  • intestinal mucosal immaturity

NEC in premature infants

The average age of onset in preterm babies is he second ane third week of life. NEC is associated with enteral feeding, but not with birth asphyxia. Higher incidence of NEC is reported in patent ductus arteriosus.

NEC in term infants

Term infants develop NEC soon after birth in babies who have not been fed yet. The likely initiating event is an ischemic insult to the gut often following birth asphyxia.

Clinical signs
  • ileus
  • bloody stools
  • abdominal wall erythema
  • systemic symptoms: apnea, bradycardia, lethargy, temperature instability, shock and consumption coagulopathy in advanced stages
  • RTG: pneumatosis intestinalis (bubbles of intramural gas), dilated loops, thickening of bowel walls and fluid levels, abdominal free air in case of perforation

Treatment: antibiotics, nothing per os, surgery (resectin of the affected portion of the bowel, ileostomy)

Complications

  • Early complications:  —  perforation and peritonitis, shock, death.
    • Mortality rate is reported 40 – 100% in infants who weight less than 1000 g compared with mortality 0 – 20% in infants who weight more than 2500 g.
  • Long-term complications: intestinal stricture, abdominal adhesions, short gut syndrome (malabsorption due to removal of excessive portions of small bowel, prolonged paranteral nutrition is necessary until the bowel grows enough)
Macroscopic appearance
  • terminal ileum is the most frequent site of involvement although any part of the small or large intestines may be involved
  • multiple lesions are common, diffuse involvement is possible
  • subserosal gas bubbles (early stage)
  • distended, congested bowel segment with frank necrotic areas
  • perforation, stercoral peritonitis
Pictures

Premature infant with birth weight 450 g. Preterm elective delivery at 25 week's gestation because of eclampsia in the mother. The infant died 6 weeks later from necrotizing enterocolitis with shock. Patent ductus arteriosus was one of the risk factors. Necrotizing enterocolitis, Macro, autopsy (73845) Necrotizing enterocolitis, Macro, autopsy (73846) Necrotizing enterocolitis, Macro, autopsy (73847) Necrotizing enterocolitis, Macro, autopsy (73848)

Necrotizing enterocolitis in slightly premature neonate with severe birth asphyxia (pH a. umbilicalis 6.7). Elective delivery because of eclampsia in the mother at 33 weeks, birth weight 1600 g. NEC affecting a short segment of terminal ileum with perforation occured as early as the third day of life. Necrotizing enterocolitis, Macro, autopsy (73853) Necrotizing enterocolitis, Macro, autopsy (73854)

Necrotizing enterocolitis in premature infant born at 31 w.g. with birth weight 1380 g, twin A. NEC was the cause of death at the age of 7 days. Necrotizing enterocolitis, Macro, autopsy (73842) Necrotizing enterocolitis, Macro, autopsy (73843) Necrotizing enterocolitis, Macro, autopsy (73844)

Necrotizing enterocolitis in premature infant born at 31 weeks with birth weight 1490 g, (twins). Necrotizing encterocolitis developed at the age of 3 weeks. Detail of the intestine: Necrotizing enterocolitis, Macro, autopsy (73849) Necrotizing enterocolitis, Macro, autopsy (73850) Necrotizing enterocolitis, Macro, autopsy (73852) Necrotizing enterocolitis, Macro, autopsy (73851)

Necrotizing enterocolitis with perforation and peritonitis in premature infant born at 25 week's gestation. NEC developed at the age of 3 weeks. Necrotizing enterocolitis, Macro, autopsy (73855) Necrotizing enterocolitis, Macro, autopsy (73856)

Necrotizing enterocolitis: Necrotizing enterocolitis, Macro, autopsy (74405) Necrotizing enterocolitis, Macro, autopsy (74406) Necrotizing enterocolitis, Macro, autopsy (74407)

Histology

Hemorhagic necrosis of the mucosal layer which may extend to transmural necrosis. Inflammatory reaction is present only in slowly developing NEC.