Patent Ductus Arteriosus in Premature Babies

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Patent Ductus Arteriosusin Premature Babies

• Dominic C. Sia, M.D.

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Neonatal Circulation

• Right to left flow
• Systemic resistance
• Pulmonary Resistance

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(No Transcript)
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Postnatally
PGE2
O2
PGE2
Nitric Oxide
O2
Prenatal Cortisol
PDA remains patent
Closure of PDA
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PDA Closure

• 24 hrs - 50
• 48 hrs - 90
• 72 hrs - 99.9

• ligamentum arteriosum
• 1-3 months

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PDA Obliteration
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PDA Obliteration
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PDA

• When the DA has not closed by 72 hrs
• Preterm infants, especially those lt30 weeks or
  lt1000 gms (50)?
• increased sensitivity to PGE2 and NO
• delayed ductal obliteration

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PDA Consequences

• Pulmonary Edema
• Pulmonary Hemorrhage
• Bronchopulmonary Dysplasia
• incidence of Necrotizing Enterocolitis
• incidence of Intraventricular Hemorrhage

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Signs and Symptoms

• 2-3 days after birth up to 1 week of life
• later in those treated with surfactant
• prominent left ventricular impulse
• bounding pulses
• widened pulse pressure (gt25 mmHg)?
• murmur
• can be initially silent
• initially systolic becoming continuous
• machinery like

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Signs and Symptoms

• deterioration of respiratory status
• circulatory instability
• cardiac enlargement
• tachypnea/apnea
• increased CO2 retention
• increased requirements for mechanical ventilation
• diagnosis confirmed by echocardiography

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Echocardiography
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Significant PDA

• Transductal diameter gt 1.5mm (_at_7-31 hrs of life)?
• Left atrial to aortic root ratio (LA/AO ratio)
  gt1.4 or gt1.5
• Left ventricular output to superior vena cava
  ratio
• (LVO/SVC ratio) gt4
• B-type Natriuretic Peptide
• Chest radiography
• cardiomegaly or pulmonary congestion
• Grading System
• oxygenation index - chest radiography
• degree of respiratory support - end-organ function

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Management

• Conservative
• Prophylactic Indomethacin/Ibuprofen
• Medical Treatment
• Indomethacin
• Ibuprofen
• Surgical Treatment

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ManagementConservative

• Neutral Thermal Environment
• Adequate Oxygenation
• PEEP
• Hct at 35-40
• Avoid exacerbating factors
• furosemide
• excessive fluids (gt170 cc/kg/day)?
• no evidence that fluid restriction reduces PDA

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ManagementMedical

• Indomethacin
• 3 doses at 12 or 24 hr intervals (0.2 mg/kg)?
• increased risk for NEC, Renal failure, Platelet
  dysfunction and BPD
• Dopamine may prevent Renal tubular dysfunction
• Regular measurement of creatinine and platelets
• Ibuprofen
• 10 mg/kg 1st dose then 5 mg/kg 2 doses daily
• less oliguria
• increased risk for NEC and platelet dysfunction
• increased risk for kernicterus

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ManagementSurgical

• complications
• blood pressure fluctuations
• respiratory compromise
• infection
• intraventricular hemorrhage
• chylothorax
• recurrent laryngeal nerve paralysis
• BPD
• death
• neurosensory impairment
• ROP

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Controversies

• Conservative Management
• high rate of spontaneous closure
• established adverse effects of intervention
• lack of evidence that treatment results in a
  decrease in neonatal morbidity and mortality
• Prophylactic Indomethacin
• 0.1 mg/kg/day q24 hrs after birth x 3 days
• no effect on mortality, pulmonary outcome or
  reducing the risk of NEC
• early treatment more likely to be successful

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Controversies

• Medical vs Surgical Treatment
• no difference in mortality
• higher adverse events with surgery

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Sources

• Clyman, RI. Ibuprofen and patent ductus
  arteriosus. N Engl J Med 2000 343728.
• Clyman, R, Cassady, G, Kirklin, JK, et al. The
  role of patent ductus arteriosus ligation in
  bronchopulmonary dysplasia reexamining a
  randomized controlled trial. J Pediatr 2009
  154873.
• Bose, CL, Laughon, MM. Patent ductus arteriosus
  lack of evidence for common treatments. Arch Dis
  Child Fetal Neonatal Ed 2007 92F498.
• Brooks, JM, Travadi, JN, Patole, SK, et al. Is
  surgical ligation of patent ductus arteriosus
  necessary? The Western Australian experience of
  conservative management. Arch Dis Child Fetal
  Neonatal Ed 2005 90F235.
• Noori, S, McCoy, M, Friedlich, P, et al. Failure
  of ductus arteriosus closure is associated with
  increased mortality in preterm infants.
  Pediatrics 2009 123e138.
• Kabra, NS, Schmidt, B, Roberts, RS, et al.
  Neurosensory impairment after surgical closure of
  patent ductus arteriosus in extremely low birth
  weight infants results from the Trial of
  Indomethacin Prophylaxis in Preterms. J Pediatr
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• Chorne, N, Leonard, C, Piecuch, R, Clyman, RI.
  Patent ductus arteriosus and its treatment as
  risk factors for neonatal and neurodevelopmental
  morbidity. Pediatrics 2007 1191165.
• Vida, V. L., Lago, P., Salvatori, S., Boccuzzo,
  G., Padalino, M. A., Milanesi, O., Speggiorin,
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  timing for surgical ligation of patent ductus
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• Noori, S., McCoy, M., Friedlich, P., Bright, B.,
  Gottipati, V., Seri, I., Sekar, K. (2009).
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  Associated With Increased Mortality in Preterm
  Infants. Pediatrics 123 e138-e144

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Sources

• El-Khuffash, A, Barry, D, Walsh, K, Davis, P G,
  Molloy, E J (2008). Biochemical markers may
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  arteriosus at high risk of death or severe
  intraventricular haemorrhage. Arch. Dis. Child.
  Fetal Neonatal Ed. 93 F407-F412
• Gaca, A. M., Jaggers, J. J., Dudley, L. T.,
  Bisset, G. S. III (2008). Repair of Congenital
  Heart Disease A Primer--Part 2. Radiology 248
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• Roberts, P., Adwani, S., Archer, N., Wilson, N.
  (2007). Catheter closure of the arterial duct in
  preterm infants. Arch. Dis. Child. Fetal Neonatal
  Ed. 92 F248-F250 Abstract Full Text
• Chorne, N., Leonard, C., Piecuch, R., Clyman, R.
  I. (2007). Patent Ductus Arteriosus and Its
  Treatment as Risk Factors for Neonatal and
  Neurodevelopmental Morbidity. Pediatrics 119
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• Patole, S K, Kumaran, V, Travadi, J N, Brooks, J
  M, Doherty, D A (2007). Does patent ductus
  arteriosus affect feed tolerance in preterm
  neonates?. Arch. Dis. Child. Fetal Neonatal Ed.
  92 F53-F55
• Manzar, S. (2006). High-Dose Indomethacin for
  Patent Ductus Arteriosus Closure How Strong Is
  the Evidence?. Pediatrics 117 1863-1863
• Sperandio, M., Beedgen, B., Linderkamp, O.
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  Arteriosus Closure How Strong Is the Evidence?
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• Fowlie, P W (2005). Managing the baby with a
  patent ductus arteriosus. More questions than
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Thank You