Membership of the Royal College of Paediatrics and Child Health (MRCPCH) Neonatology and Perinatal Medicine Syllabus

Neonatology and Perinatal Medicine syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Neonatology and Perinatal Medicine in Membership of the Royal College of Paediatrics and Child Health (MRCPCH), not a summary of it.

1. 1

   Fetal Medicine and Birth

   5 topics

   • Fetal physiology and circulation
   • Antenatal screening and diagnosis
   • Maternal conditions affecting the fetus
     • Gestational diabetes and maternal infection
     • Drugs, alcohol and substance exposure
   • Transition and adaptation at birth
   • Newborn resuscitation (NLS algorithm)
2. 2

   Care of the Newborn

   5 topics

   • Routine newborn examination (NIPE)
     • Developmental dysplasia of the hip
     • Congenital heart disease screening
   • Newborn bloodspot and hearing screening
   • Neonatal jaundice
     • Physiological vs pathological jaundice
     • Phototherapy and exchange transfusion thresholds
     • Kernicterus and bilirubin encephalopathy
   • Feeding and hypoglycaemia of the newborn
   • Birth trauma and brachial plexus injury
3. 3

   The Preterm and Low Birth Weight Infant

   7 topics

   • Respiratory distress syndrome and surfactant therapy
   • Bronchopulmonary dysplasia and chronic lung disease
   • Apnoea of prematurity
   • Patent ductus arteriosus
     • Haemodynamic significance and management
   • Necrotising enterocolitis
   • Intraventricular haemorrhage and periventricular leukomalacia
   • Retinopathy of prematurity
4. 4

   Neonatal Emergencies and Intensive Care

   6 topics

   • Hypoxic-ischaemic encephalopathy and therapeutic cooling
   • Neonatal respiratory support
     • CPAP, ventilation and high-frequency strategies
     • Pneumothorax and air leaks
   • Persistent pulmonary hypertension of the newborn
   • Neonatal sepsis and meningitis
     • Early- and late-onset sepsis
     • Group B streptococcus prevention
   • Neonatal seizures
   • Inborn errors presenting in the neonatal period
5. 5

   Neonatal Surgical and Genetic Conditions

   5 topics

   • Congenital diaphragmatic hernia
   • Abdominal wall defects (gastroschisis, exomphalos)
   • Oesophageal atresia and tracheo-oesophageal fistula
   • Bowel obstruction and atresias
   • Dysmorphology and common syndromes

Neonatology and Perinatal Medicine flashcards for Membership of the Royal College of Paediatrics and Child Health (MRCPCH)

22 of 57 cards from the Neonatology and Perinatal Medicine deck — real questions with worked answers.

1. In the fetal circulation, which three vascular shunts divert blood away from the lungs and liver?

   The ductus venosus (bypasses the liver, shunting oxygenated umbilical venous blood to the IVC), the foramen ovale (right atrium to left atrium), and the ductus arteriosus (pulmonary artery to descending aorta).

2. Which fetal vessels carry the most and least oxygenated blood, and what are the approximate fetal oxygen saturations?

   The single umbilical vein carries the most oxygenated blood (PO2 ~30-35 mmHg, sats ~80%); the two umbilical arteries carry deoxygenated blood back to the placenta. Fetal arterial sats are low (~60-65%) because of mixing, but high fetal haemoglobin and high cardiac output maintain oxygen delivery.

3. Why does fetal haemoglobin (HbF) have a higher oxygen affinity than adult haemoglobin?

   HbF ($\alpha_2\gamma_2$) binds 2,3-DPG poorly, shifting its oxygen-dissociation curve to the left (lower $P_{50}$ ~19 mmHg vs ~27 mmHg for HbA). This facilitates oxygen uptake from maternal blood across the placenta.

4. What does the combined test for antenatal screening of trisomy 21 measure, and when is it performed?

   Performed at 11-14 weeks: maternal age, nuchal translucency (ultrasound), free $\beta$-hCG (raised in T21) and PAPP-A (low in T21). The quadruple test (AFP, hCG, uE3, inhibin A) is the alternative at 14-20 weeks.

5. How do maternal serum markers differ between Down syndrome (T21) and Edwards syndrome (T18) on the combined/quadruple test?

   T21: low PAPP-A, high $\beta$-hCG, low AFP, low uE3, high inhibin A, increased nuchal translucency. T18 (Edwards): all of PAPP-A, hCG, AFP and uE3 are typically low.

6. Compare chorionic villus sampling (CVS) and amniocentesis in timing and miscarriage risk.

   CVS is done from ~11 weeks (transabdominal/transcervical sampling of placental villi) with a miscarriage risk of ~1-2%. Amniocentesis is done from ~15 weeks (amniotic fluid sampling) with a risk of ~0.5-1%. CVS gives earlier results but carries a higher risk and possible confined placental mosaicism.

7. What is the effect of poorly controlled maternal diabetes on the fetus and neonate?

   Fetal hyperinsulinaemia causes macrosomia, organomegaly, polycythaemia, increased risk of congenital malformations (cardiac, sacral agenesis, neural tube defects), neonatal hypoglycaemia, hypocalcaemia, RDS (delayed surfactant) and polycythaemic jaundice.

8. Which maternal antibody causes congenital heart block, and via which mechanism?

   Maternal anti-Ro (SSA) and anti-La (SSB) antibodies (seen in SLE/Sjögren) cross the placenta and damage the fetal cardiac conduction system, causing congenital complete heart block, often requiring pacing.

9. List the classic features of the congenital varicella syndrome.

   Results from maternal chickenpox before 20 weeks: cicatricial skin scarring in a dermatomal distribution, limb hypoplasia, eye defects (chorioretinitis, cataracts, microphthalmia), and neurological abnormalities (microcephaly, cortical atrophy).

10. What cardiovascular and respiratory changes occur at birth to establish the transition to neonatal circulation?

    Lung expansion and rising $PaO_2$ drop pulmonary vascular resistance; removal of the low-resistance placenta raises systemic vascular resistance. Increased left atrial pressure functionally closes the foramen ovale; the rising $PaO_2$ and falling prostaglandins close the ductus arteriosus; the ductus venosus closes as umbilical flow stops.

11. What is the role of fetal lung fluid clearance at birth and what drives it?

    Fetal lung fluid is actively reabsorbed via amiloride-sensitive epithelial sodium (ENaC) channels, upregulated by the catecholamine and cortisol surge of labour. Failure of clearance (e.g. elective caesarean) causes transient tachypnoea of the newborn (TTN).

12. In the Newborn Life Support (NLS) algorithm, what are the first inflation breaths and how are they delivered?

    After drying, assessing and a 60-second initial assessment, give 5 inflation breaths (each held ~2-3 seconds) at an inflation pressure of ~30 cmH2O in term infants (20-25 cmH2O in preterm), in air for term infants. Then reassess heart rate and chest movement.

13. What is the compression-to-ventilation ratio in newborn resuscitation, and when is it started?

    Chest compressions are started if the heart rate remains below 60 bpm despite effective ventilation (good chest rise). The ratio is 3:1 (3 compressions to 1 ventilation), aiming for ~90 compressions and 30 breaths per minute.

14. In newborn resuscitation, what dose and route of adrenaline is used?

    Adrenaline $10\text{-}30\ \mu g/kg$ (0.1-0.3 mL/kg of 1:10,000) IV, ideally via an umbilical venous catheter, if heart rate remains below 60 bpm despite effective ventilation and compressions. The tracheal route is unreliable.

15. What are the recommended target preductal oxygen saturations during newborn resuscitation in the first 10 minutes?

    Approximately: 2 min 60%, 3 min 70%, 4 min 80%, 5 min 85%, 10 min 90%. Saturations are measured preductally (right hand/wrist).

16. List the components of the routine Newborn and Infant Physical Examination (NIPE) and its timing.

    Performed within 72 hours of birth and repeated at 6-8 weeks. It specifically examines four areas: eyes (red reflex for cataract/retinoblastoma), heart (murmurs, femoral pulses), hips (Barlow and Ortolani for DDH), and testes (descent in boys).

17. What are the Barlow and Ortolani manoeuvres testing for, and how do they differ?

    Both screen for developmental dysplasia of the hip. Barlow is provocative — adduct and push posteriorly to dislocate a dislocatable hip. Ortolani is reductive — abduct and lift to relocate a dislocated hip (palpable clunk). A positive test prompts ultrasound.

18. Which nine conditions are screened for on the UK newborn bloodspot (Guthrie) card, and when is it taken?

    Taken at day 5: phenylketonuria, congenital hypothyroidism, sickle cell disease, cystic fibrosis, MCADD, maple syrup urine disease, isovaleric acidaemia, glutaric aciduria type 1, and homocystinuria.

19. What test is used for newborn hearing screening, and what is its principle?

    Otoacoustic emissions (OAE) are used first — a probe plays sound and detects echoes from healthy outer hair cells. If the OAE is abnormal, the automated auditory brainstem response (AABR) is performed, which tests the whole auditory pathway to the brainstem.

20. What distinguishes physiological from pathological neonatal jaundice based on timing?

    Jaundice in the first 24 hours of life is always pathological (usually haemolysis — e.g. rhesus/ABO, G6PD, sepsis). Physiological jaundice peaks at day 3-5 and resolves by day 14 (term). Prolonged jaundice is >14 days (term) or >21 days (preterm) and needs investigation.

21. What is the pathophysiology of kernicterus and which bilirubin fraction is responsible?

    Unconjugated (lipid-soluble, fat-soluble) bilirubin crosses the blood-brain barrier and deposits in the basal ganglia and brainstem nuclei, causing bilirubin encephalopathy. It presents with lethargy, hypertonia, opisthotonus, and a high-pitched cry; survivors develop choreoathetoid cerebral palsy, sensorineural deafness and upward gaze palsy.

22. Compare the causes of unconjugated versus conjugated neonatal hyperbilirubinaemia.

    Unconjugated: haemolysis (rhesus/ABO, G6PD, spherocytosis), physiological, breast milk jaundice, sepsis, hypothyroidism, Crigler-Najjar. Conjugated (>25 µmol/L or >20% of total): biliary atresia, neonatal hepatitis, TPN, choledochal cyst, metabolic disease — always pathological and needs urgent investigation (biliary atresia is time-critical).

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