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CONGENITAL ANOMALIES
Mrs. Santhoshkumari. M,
MSc (N), PhD, MSc (Psy), PGDHM
Faculty in Nursing
College of Nursing,IGMC&RI
Puducherry
OTHER NAMES…
Congenital
Disorders
Congenital
Malformations
Birth
Defects
CAUSES & RISK FACTORS…
Socio-economic Factors
DemographicFactors
Advanced Maternal Age
Genetic factors
Infections – Syphilis, Rubella
Maternal Nutritional Status
Iodine, Folate, Obesity, DM, Excessive Vitamin A intake
Environmental Factors
Pesticides, chemicals, alcohol, tobacco, psychoactive
drugs, radiation, living near waste sites
DETECTION…
Pre-conception
Screening
Peri-conception
Screening
Neonatal
Screening
TREATMENT
Surgery
Early Treatment for
functional problems
Thalassemia
Sickle cell disorders
Congenital
hypothyroidism
PREVENTION…
Improving Diet
Avoid intake of harmful substances
Control pre-conceptional & Gestational Diabetes
Avoid exposure to hazardous substances
Justified exposure to radiation & medications
Vaccination Coverage - Rubella
Health education on prevention
CNS ANOMALIES
CNS MALFORMATIONS
Failure in
Embryological Development
Or
Chromosomal Abnormality
CONDITIONS
Cranial
Deformities
Spina
Bifida
Hydrocephalous
Cerebral
Palsy
Meningocele
NEURAL TUBE
DEFECTS
WHAT IS NEURAL TUBE DEFECT ?
 Failure of normal fusion of the neural plate to
form neural tube during the first 28 days
following conception .
 Neural tube defects (NTDs) are one of the
most common birth defects, occurring in
approximately one in 1000 live births in the
United States.
NEURAL TUBE DEVELOPMENT
 Normal
embryological
development
 Neural plate
development -
18th day
 Cranial closure
24th day (upper
spine)
 Caudal closure
26th day (lower
spine)
CLASSIFICATION
Neural
Tube
Defects
Open
Spina
Bifida
Anencephaly
Encephalocel
e
Closed
(Rare)
Meningocele
Myelo-
meningocele
What are the
common
Neural Tube Defects (NTDs) ?
NEURAL TUBE DEFECTS
 Spina Bifida - 60%
 Anencephaly - 30%
 Encephalocele - 10%
WHAT IS SPINA BIFIDA?
- A midline defect of the :
 bone,
 skin,
 spinal column, &/or
 spinal cord.
Latin
Word
Split
Open
spine
SPINA BIFIDA
Spina Bifida Occulta
(closed)
.
Spina Bifida Cystic
(open)
SPINA BIFIDA
SPINA BIFIDA OCCULTA
Symbtoms :
 Difficulties controlling bowel or bladder .
 weakness and numbness in the feet
 recurrent ulceration .
 neurological deficits increase with
growth.
Signs :
 Overlying skin lesion :
 tuft hair - lipoma - birth mark or small
dermal sinus
 Usually in the lumbar region .
SPINA BIFIDA OCCULTA
 Diagnosis:
-indecently by X-ray.
- clinical.
MYELOMENINGOCELE
MYELOMENINGOCELE
 The spinal cord and nerve roots herniate into
a sac comprising the meninges.
 This sac protrudes through the bone and
musculocutaneous defect.
CLINICAL MALFORMATIONS
Hydrocephalus
Impaired cognitive Development
Chiari II malformation
Paralysis
Ortho problems – Scoliosis, kyphosis, hip dislocation,
joint deformities, club foot, weak bones
Nervous System problems – weakness, back
pain & leg pain
Bladder or bowel problems
Kidney damage or tethered cord
DIAGNOSIS
Prenatal
Ultrasound
MRI
Amniocentesis
After birth
Examination
Trans-illumination test
CT scan or MRI
Laboratory tests
Spinal tomogram or myelogram
SURGICAL MANAGEMENT
 Laminectomy
 Closure of open lesion
 Removal of sac
NURSING MANAGEMENT
Prevention of infection:
 Avoid positioning on back
 Observe the sac frequently for CSF leakage
 Avoid contamination by urine and feces
 Avoid placing diaper or cloth over sac
 Keep buttocks and genitalia clean
 Apply sterile gauze pad or towel or sterile moistened dressing
over the sac
 Monitor for any oozing of fluid or pus
 Fever
 Irritability
 Listlessness
 Seizure
NURSING MANAGEMENT
Maintaining cerebral tissue perfusion:
 Monitor for signs of hydrocephalous
- irritability
- feeding difficulty
- vomitting
- decreased appetite
- temperature fluctuation
- decreased alertness
- tense fontanelle
- increased head circumference
NURSING MANAGEMENT
Promoting Urinary Elimination:
 Apply firm pressure to abdomen from
umbilical area to symphysis pubis
 Ensure fluid intake to dilute the urine
 Prophylactic antibiotics
 Monitor for concentrated or foul smelling
urine
NURSING MANAGEMENT
Maintaining thermoregulation & preventing
complications:
 TPR monitoring
 Colour
 Level of responsivenness
 Prevent respiratory complications
 Oxygenation
 Clean dressing
ASSIGNMENT
 Live images of Congenital anomalies from
your clinical postings
ARNOLD CHIARI MALFORMATION
 Herniation of the cerebellar tonsils
through the foramen magnum .
 cerebellar hypoplasia .
 caudal displacement
of the hindbrain through .
the foramen magnum .
 usually associated with
Hydrocephalus .
ARNOLD CHIARI MALFORMATION
 Hydrocephalus .
 Cranial Nerve Palsies .
 Visual Deficits .
 Pressure from the enlarged ventricles
affecting adjacent brain structures .
 Cognitive and perceptual problems.
 Motor dysfunction .
MENINGOCELE
simply herniation of the meninges through the bony
defect (spina bifida).
MENINGOCELE
 Fluid-filled sac with meninges involved but
neural tissue unaffected .
 The spinal cord and nerve roots do not
herniate into this dorsal dural sac.
 The primary problems with this deformity are
cosmetic
MENINGOCELE
 Neonates with a meningocele usually have
normal findings upon physical examination
and a covered (closed) dural sac.
 Neonates with meningocele do not have
associated neurologic malformations such as
hydrocephalus or Chiari II.
 May complicted by CSF infection.
LIPOMENINGOCELE
 Lipomeningocele
(lipo = fat)
 lipoma or fatty tumor
located over the
lumbosacral spine.
 Associated with bowel
& bladder dysfunction
Lipomeningocele
PROGNOSIS OF SPINA BIFIDA
o static
o non-progressive defect
o with worsening from secondary problems.
- The prognosis for a normal life span is generally
good for a child with good health habits and a
supportive family/caregiver.
IMPAIRMENTS ASSOCIATED WITH SPINA BIFIDA
 Abnormal eye movement
 Pressure sore and skin irritations.
 Latex allergy.
 Bladder and bowel control problems
 musculoskeletal deformities (scoliosis).
 joint and extremity deformities (joint
contractures, club foot, hip
subluxations, diminished growth of non-
weight bearing limbs)
 Osteoporosis.
 tethered spinal cord after surgery .
 Treatment
 surgical
 Management
 Prenatal screening
 Triple Screen( alpha fetoprotein ,hcg ,esraiol )
 Ultrasound
 amniocentesis
 complex and life long
 Spine Xrays and/or spinal ultrasound
ANENCEPHALY
 Failure of development of most of the
cranium and brain.
 Infants are born without the main part of
the forebrain-the largest part of the
cerebrum.
 The fetus usually blind, deaf and unconscious .
partially destroyed brain, deformed
forehead, and large ears and eyes with
often relatively normal lower facial
structures.
 Both genetic and environmental insults
appear to be responsible for this
outcome.
 The defect normally occurs after neural
fold development at day 16 of gestation
but before closure of the anterior
neuropore at 24-26 days' gestation.
ANENCEPHALY
 Anencephaly is the most common
major CNS malformation in the Western
world,
 no neonates survive. It is seen 37 times
more in females than in males.
 The recurrence rate in families can be as
high as 35%.
ANENCEPHALY
 Symptoms
 Mom- Polyhydramnios
 Baby- absence of brain/skull
 Diagnosis
 Ultrasound
 Treatment
 None, incompatible with life
 Management
 Comfort Measures
 Support Parents
ENCEPHALOCELE
 Extrusion of brain and
meninges through a
midline
Skull defect .
 - Often associated with
cerebral malformation
DIAGNOSIS AND DETECTION
 Amniocentesis
 AFP - indication of abnormal leakage
 Blood test
 Maternal blood samples of AFP
 Ultrasonography
 For locating back lesion vs. cranial signs
C/C :
Bulging on the back or other deformity .
HPI :
Onset(at birth).
Size.
Course( progressive or constant)
Associated symptoms .
Past medical hx :
Previous medical problems .
Previous hospitalization.
Previous surgery or shunt .
Pregnancy & neonatal hx :
Follow up during pregnancy or no .
Mother’s illness during pregnancy .
Mother’s medication during pregnancy (anticonvlsion)
Exposure of the mother to radiation.
Exposure to high temperatures early in pregnancy
Taking Folic acid in 1st trimester.
Gestational age
Type of delivery
Birth weight
Other Congenital anomalies
Apgar scores
Admission to NICU
Developmental hx:
According to age .
Family & social hx :
Age of parents.
Consanguinity.
History of NTD in family .
History of diabetes of mother.
History of using anti-seizure for mother.
Obesity mother .
History of stillbirth or abortion
History of neonatal death in family.
General examination:
Child appearance
Vital signs.
Growth parameter ( HC imp)
Examination of the head & neck :
Anterior Fontanel : wide bulging
Separated suture .
Dilated scalp vein .
Setting sun eye sign .
May be neck stiffness .
Examination of cranial nerve .
Examination of the back:
Inspection for deformity , scar, bulging( size, content)
pressure sores and skin irritations
sensation .
Examination of lower limps :
Inspection for deformity, muscle bulk .
Exam for tone and power (maybe paralysis)
Reflex and sensation ,
Gait .
Remember : urinary and bowel sphincters (maybe affected)
Management
Management varies according to the type and
severity of neural tube defect
Treatment of mylomenigocele
- Genetic counseling may be recommended. In some cases where
severe defect is detected early in the pregnancy, a therapeutic
abortion may be considered
 After birth - surgery to repair the defect is usually recommended
at an early age. Before surgery, the infant must be handled
carefully to reduce damage to the exposed spinal cord. This may
include special care and positioning, protective devices, and
changes in the methods of handling, feeding, and bathing.
Hydrocephalus:
- Children who also have hydrocephalus may
need a ventricular peritoneal shunt
This will help drain the extra fluid
- Antibiotics may be used to treat or prevent
infections such as meningitis or urinary tract
infections
Most children will require lifelong treatment for problems that result from
damage to the spinal cord and spinal nerves. This includes :
- Gentle downward pressure over the bladder may help drain the bladder.
In severe cases, drainage tubes, called catheters, may be needed.
Bowel training programs and a high fiber diet may improve bowel
function
- Orthopedic or physical therapy may be needed to treat musculoskeletal
symptoms. Braces may be needed for muscle and joint problems
- Neurological losses are treated according to the type and severity of
function loss
- Follow-up examinations generally continue
throughout the child's life. These are done to
check the child's developmental level and to
treat any intellectual, neurological, or
physical problems
Treatment of menigocele
The key priorities in the treatment of
meningocele are to prevent infection from
developing through the tissue of the defect
on the spine and to protect the exposed
structures from additional trauma. Most
children with meningocele are treated with
surgery (within the first few days of life) to
close the defect and to prevent infection or
further trauma
Management of spina bifida occulta
- can remove fat or fibrous tissues which are
affecting the functioning of the spinal cord
- can drain syrinxes or cysts in the spinal canal
to reduce pressure on the spinal cord and
- can be performed on the legs or feet to
improve their functioning
General management
- braces, supports and corrective casts
- physiotherapy to improve physical strength and coordination
- therapeutic strategies for improving mobility
- surgical care
- medical strategies for improving bladder and bowel functioning :
 intermittent catheterization
 voiding and cleansing routines
 medications
 diet with adequate fiber and fluids
 possible surgical reconstruction (urinary)
- psychological strategies for personal and social adjustment
medications
SUMMERY :
 Prevention
 folic acid 0.4 mg daily pre, 1 mg daily preg
 Identify
 Prenatal
 At birth
 Protect pre-op and post-op
 Skin integrity to prevent infection
 Special handling to reduce nerve damage
 Support
 Parental coping
 Pictures of similar defects corrected
 Genetic Counseling
 For future pregnancy
 In early pregnancy, therapeutic abortion
 Complications
 Permanent disability
 Education
 Symptoms of hydrocephalus
 Symptoms of meningitis
 Follow up for monitoring to assess neurologic damage
HOW CAN NTDS BE PREVENTED?
 All women of childbearing age should receive
0.4 mg (400 micrograms) of folic acid daily prior
to conception of planned or unplanned
pregnancies and continue thru 1st trimester
 Women with a history of NTD and should
receive daily supplementation of (4000
micrograms) of folic acid starting three months
prior to conception and continuing thru the 1st
trimester
THANK YOU

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Congenital anomalies/Neural tube defects/ birth defects

  • 1. CONGENITAL ANOMALIES Mrs. Santhoshkumari. M, MSc (N), PhD, MSc (Psy), PGDHM Faculty in Nursing College of Nursing,IGMC&RI Puducherry
  • 2.
  • 4. CAUSES & RISK FACTORS… Socio-economic Factors DemographicFactors Advanced Maternal Age Genetic factors Infections – Syphilis, Rubella Maternal Nutritional Status Iodine, Folate, Obesity, DM, Excessive Vitamin A intake Environmental Factors Pesticides, chemicals, alcohol, tobacco, psychoactive drugs, radiation, living near waste sites
  • 6. TREATMENT Surgery Early Treatment for functional problems Thalassemia Sickle cell disorders Congenital hypothyroidism
  • 7. PREVENTION… Improving Diet Avoid intake of harmful substances Control pre-conceptional & Gestational Diabetes Avoid exposure to hazardous substances Justified exposure to radiation & medications Vaccination Coverage - Rubella Health education on prevention
  • 9. CNS MALFORMATIONS Failure in Embryological Development Or Chromosomal Abnormality
  • 12. WHAT IS NEURAL TUBE DEFECT ?  Failure of normal fusion of the neural plate to form neural tube during the first 28 days following conception .  Neural tube defects (NTDs) are one of the most common birth defects, occurring in approximately one in 1000 live births in the United States.
  • 13. NEURAL TUBE DEVELOPMENT  Normal embryological development  Neural plate development - 18th day  Cranial closure 24th day (upper spine)  Caudal closure 26th day (lower spine)
  • 15. What are the common Neural Tube Defects (NTDs) ?
  • 16. NEURAL TUBE DEFECTS  Spina Bifida - 60%  Anencephaly - 30%  Encephalocele - 10%
  • 17. WHAT IS SPINA BIFIDA? - A midline defect of the :  bone,  skin,  spinal column, &/or  spinal cord. Latin Word Split Open spine
  • 18. SPINA BIFIDA Spina Bifida Occulta (closed) . Spina Bifida Cystic (open)
  • 20. SPINA BIFIDA OCCULTA Symbtoms :  Difficulties controlling bowel or bladder .  weakness and numbness in the feet  recurrent ulceration .  neurological deficits increase with growth. Signs :  Overlying skin lesion :  tuft hair - lipoma - birth mark or small dermal sinus  Usually in the lumbar region .
  • 21. SPINA BIFIDA OCCULTA  Diagnosis: -indecently by X-ray. - clinical.
  • 23. MYELOMENINGOCELE  The spinal cord and nerve roots herniate into a sac comprising the meninges.  This sac protrudes through the bone and musculocutaneous defect.
  • 24. CLINICAL MALFORMATIONS Hydrocephalus Impaired cognitive Development Chiari II malformation Paralysis Ortho problems – Scoliosis, kyphosis, hip dislocation, joint deformities, club foot, weak bones Nervous System problems – weakness, back pain & leg pain Bladder or bowel problems Kidney damage or tethered cord
  • 26. SURGICAL MANAGEMENT  Laminectomy  Closure of open lesion  Removal of sac
  • 27.
  • 28. NURSING MANAGEMENT Prevention of infection:  Avoid positioning on back  Observe the sac frequently for CSF leakage  Avoid contamination by urine and feces  Avoid placing diaper or cloth over sac  Keep buttocks and genitalia clean  Apply sterile gauze pad or towel or sterile moistened dressing over the sac  Monitor for any oozing of fluid or pus  Fever  Irritability  Listlessness  Seizure
  • 29. NURSING MANAGEMENT Maintaining cerebral tissue perfusion:  Monitor for signs of hydrocephalous - irritability - feeding difficulty - vomitting - decreased appetite - temperature fluctuation - decreased alertness - tense fontanelle - increased head circumference
  • 30. NURSING MANAGEMENT Promoting Urinary Elimination:  Apply firm pressure to abdomen from umbilical area to symphysis pubis  Ensure fluid intake to dilute the urine  Prophylactic antibiotics  Monitor for concentrated or foul smelling urine
  • 31. NURSING MANAGEMENT Maintaining thermoregulation & preventing complications:  TPR monitoring  Colour  Level of responsivenness  Prevent respiratory complications  Oxygenation  Clean dressing
  • 32.
  • 33. ASSIGNMENT  Live images of Congenital anomalies from your clinical postings
  • 34.
  • 35. ARNOLD CHIARI MALFORMATION  Herniation of the cerebellar tonsils through the foramen magnum .  cerebellar hypoplasia .  caudal displacement of the hindbrain through . the foramen magnum .  usually associated with Hydrocephalus .
  • 36. ARNOLD CHIARI MALFORMATION  Hydrocephalus .  Cranial Nerve Palsies .  Visual Deficits .  Pressure from the enlarged ventricles affecting adjacent brain structures .  Cognitive and perceptual problems.  Motor dysfunction .
  • 37. MENINGOCELE simply herniation of the meninges through the bony defect (spina bifida).
  • 38. MENINGOCELE  Fluid-filled sac with meninges involved but neural tissue unaffected .  The spinal cord and nerve roots do not herniate into this dorsal dural sac.  The primary problems with this deformity are cosmetic
  • 39. MENINGOCELE  Neonates with a meningocele usually have normal findings upon physical examination and a covered (closed) dural sac.  Neonates with meningocele do not have associated neurologic malformations such as hydrocephalus or Chiari II.  May complicted by CSF infection.
  • 40. LIPOMENINGOCELE  Lipomeningocele (lipo = fat)  lipoma or fatty tumor located over the lumbosacral spine.  Associated with bowel & bladder dysfunction Lipomeningocele
  • 41. PROGNOSIS OF SPINA BIFIDA o static o non-progressive defect o with worsening from secondary problems. - The prognosis for a normal life span is generally good for a child with good health habits and a supportive family/caregiver.
  • 42. IMPAIRMENTS ASSOCIATED WITH SPINA BIFIDA  Abnormal eye movement  Pressure sore and skin irritations.  Latex allergy.  Bladder and bowel control problems  musculoskeletal deformities (scoliosis).  joint and extremity deformities (joint contractures, club foot, hip subluxations, diminished growth of non- weight bearing limbs)  Osteoporosis.  tethered spinal cord after surgery .
  • 43.  Treatment  surgical  Management  Prenatal screening  Triple Screen( alpha fetoprotein ,hcg ,esraiol )  Ultrasound  amniocentesis  complex and life long  Spine Xrays and/or spinal ultrasound
  • 44. ANENCEPHALY  Failure of development of most of the cranium and brain.  Infants are born without the main part of the forebrain-the largest part of the cerebrum.
  • 45.  The fetus usually blind, deaf and unconscious . partially destroyed brain, deformed forehead, and large ears and eyes with often relatively normal lower facial structures.  Both genetic and environmental insults appear to be responsible for this outcome.  The defect normally occurs after neural fold development at day 16 of gestation but before closure of the anterior neuropore at 24-26 days' gestation.
  • 46. ANENCEPHALY  Anencephaly is the most common major CNS malformation in the Western world,  no neonates survive. It is seen 37 times more in females than in males.  The recurrence rate in families can be as high as 35%.
  • 47. ANENCEPHALY  Symptoms  Mom- Polyhydramnios  Baby- absence of brain/skull  Diagnosis  Ultrasound  Treatment  None, incompatible with life  Management  Comfort Measures  Support Parents
  • 48. ENCEPHALOCELE  Extrusion of brain and meninges through a midline Skull defect .  - Often associated with cerebral malformation
  • 49. DIAGNOSIS AND DETECTION  Amniocentesis  AFP - indication of abnormal leakage  Blood test  Maternal blood samples of AFP  Ultrasonography  For locating back lesion vs. cranial signs
  • 50.
  • 51. C/C : Bulging on the back or other deformity . HPI : Onset(at birth). Size. Course( progressive or constant) Associated symptoms . Past medical hx : Previous medical problems . Previous hospitalization. Previous surgery or shunt .
  • 52. Pregnancy & neonatal hx : Follow up during pregnancy or no . Mother’s illness during pregnancy . Mother’s medication during pregnancy (anticonvlsion) Exposure of the mother to radiation. Exposure to high temperatures early in pregnancy Taking Folic acid in 1st trimester. Gestational age Type of delivery Birth weight Other Congenital anomalies Apgar scores Admission to NICU Developmental hx: According to age .
  • 53. Family & social hx : Age of parents. Consanguinity. History of NTD in family . History of diabetes of mother. History of using anti-seizure for mother. Obesity mother . History of stillbirth or abortion History of neonatal death in family.
  • 54. General examination: Child appearance Vital signs. Growth parameter ( HC imp) Examination of the head & neck : Anterior Fontanel : wide bulging Separated suture . Dilated scalp vein . Setting sun eye sign . May be neck stiffness .
  • 55. Examination of cranial nerve . Examination of the back: Inspection for deformity , scar, bulging( size, content) pressure sores and skin irritations sensation . Examination of lower limps : Inspection for deformity, muscle bulk . Exam for tone and power (maybe paralysis) Reflex and sensation , Gait . Remember : urinary and bowel sphincters (maybe affected)
  • 57. Management varies according to the type and severity of neural tube defect
  • 58. Treatment of mylomenigocele - Genetic counseling may be recommended. In some cases where severe defect is detected early in the pregnancy, a therapeutic abortion may be considered  After birth - surgery to repair the defect is usually recommended at an early age. Before surgery, the infant must be handled carefully to reduce damage to the exposed spinal cord. This may include special care and positioning, protective devices, and changes in the methods of handling, feeding, and bathing.
  • 59. Hydrocephalus: - Children who also have hydrocephalus may need a ventricular peritoneal shunt This will help drain the extra fluid - Antibiotics may be used to treat or prevent infections such as meningitis or urinary tract infections
  • 60. Most children will require lifelong treatment for problems that result from damage to the spinal cord and spinal nerves. This includes : - Gentle downward pressure over the bladder may help drain the bladder. In severe cases, drainage tubes, called catheters, may be needed. Bowel training programs and a high fiber diet may improve bowel function - Orthopedic or physical therapy may be needed to treat musculoskeletal symptoms. Braces may be needed for muscle and joint problems - Neurological losses are treated according to the type and severity of function loss
  • 61. - Follow-up examinations generally continue throughout the child's life. These are done to check the child's developmental level and to treat any intellectual, neurological, or physical problems
  • 62. Treatment of menigocele The key priorities in the treatment of meningocele are to prevent infection from developing through the tissue of the defect on the spine and to protect the exposed structures from additional trauma. Most children with meningocele are treated with surgery (within the first few days of life) to close the defect and to prevent infection or further trauma
  • 63. Management of spina bifida occulta - can remove fat or fibrous tissues which are affecting the functioning of the spinal cord - can drain syrinxes or cysts in the spinal canal to reduce pressure on the spinal cord and - can be performed on the legs or feet to improve their functioning
  • 64. General management - braces, supports and corrective casts - physiotherapy to improve physical strength and coordination - therapeutic strategies for improving mobility - surgical care - medical strategies for improving bladder and bowel functioning :  intermittent catheterization  voiding and cleansing routines  medications  diet with adequate fiber and fluids  possible surgical reconstruction (urinary) - psychological strategies for personal and social adjustment medications
  • 65. SUMMERY :  Prevention  folic acid 0.4 mg daily pre, 1 mg daily preg  Identify  Prenatal  At birth  Protect pre-op and post-op  Skin integrity to prevent infection  Special handling to reduce nerve damage  Support  Parental coping  Pictures of similar defects corrected  Genetic Counseling  For future pregnancy  In early pregnancy, therapeutic abortion  Complications  Permanent disability  Education  Symptoms of hydrocephalus  Symptoms of meningitis  Follow up for monitoring to assess neurologic damage
  • 66. HOW CAN NTDS BE PREVENTED?  All women of childbearing age should receive 0.4 mg (400 micrograms) of folic acid daily prior to conception of planned or unplanned pregnancies and continue thru 1st trimester  Women with a history of NTD and should receive daily supplementation of (4000 micrograms) of folic acid starting three months prior to conception and continuing thru the 1st trimester
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