early diagnosis and management of pda

8/2/2019 Early Diagnosis and Management of Pda

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E A R L Y D IA G N O S IS A N D M A N A G E M E N T

O F P D A

R I A N O V A

D e p a rtm e n t o f C h ild H e a lthF a culty of M e d ic ine , U nive rs ity of S riwija ya /

M o h .H o e s in H o s p ita l P a le m b a n g


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INTRODUCTION

P DA is a pers is tence of the fetal connectionbetween aorta and artery pulmonalis afterbirth

P DA

Isolated PDA

P art of complex cardiac abnormality

Isolated P DA 1 in 2500 to 5000 live births

Moore P et al. Moss and Adam 2008;683-99


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INTRODUCTION

P DA is more common in :

P remature infants

B W < 1750 g : 45%

B W < 1200 g : 80%

G enetic abnormalities

Infants whose mother had G erman meas les

(R ubella)

P DA in preterm haemodynamic instability

co-morbidity & mortality E A R L Y

DIAGNOSIS Nick A . Arch of Dis in C hildhood1993;69:529-32


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HEMODYNAMIC


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DIAGNOSIS


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DIAGNOSIS

The typical physical findings continuous

or machinery murmur

T he newborn :

not detectable by auscultation for several

weeks

Large ductus : , bounding peripheral pulse

hyperactive precordium,systolic

murmur,localizedNick A . Arch of Dis in C hildhoohd

1993;69:529-32


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DIAGNOSIS

C linical examination

C ontinuous

(machinery)murmur

Diastolic flow rumble

murmur

P ark MK . 5th edition.2008


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C hest X -R ay

L arge P DA:P rominence of the left

atrium,

left ventricle, ascending

aorta,

Pulmonary vascular

marking


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E C G

S mall P DA : normal

Moderate P DA : L VH

L arge P DA : B VH P DA with P VO D : R VH


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E C H O C A R D I O G R A P H Y


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E C H O C A R D I O G R A P H Y


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MANAGEMENT

Medical treatment : prostaglandin synthes isinhibitor

Preterm neonates : usefull

Aterm neonates : useless

T ranscatheter closure : mostly choice treatment

S urgical closure :

Infant < 5 kg with large P DA

Preterm neonates : medical treatment unsuccessful

or contraindicated


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T R ANS C AT HE T E R C L OS UR E

Al A ta et al. C ardiol Y oung,2005;15:279-85

Wong J K et al. C atheter C ardiovas c Inter2007;69(4):572-8

*Transcatheter occlusion is effective with a high rate of completeoccl

*C omplication rare


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A D

O

T R A N S C A T H E T E R C L O S U R E


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P D A IN P R E T E R M NE O NAT E S

S pecial problem : haemodynamic instability

T reatment should be s tarted as soon as P DA

suspected

Once a s ignificant shunt is pres ent

increased pulmonary blood flow damag e to

premature lungs

P DA can be c losed with prostaglandin

synthesis inhibitorsC ooke et al. C hochrane Database S yst R ev2003


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P R O S T AG L AND IN S Y NT H E S IS

INHIBITOR

Indomethacin

Initial dose : 0.2 mg/kg

S ubsequent dose

7 day: 0.25 mg/kg/dose 12 hourly for 2 doses

Ibuprofen : alternative agent 10 mg/kg stat followed by

5 mg/kg/dos e 24 hourly for 2 dos es


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Indomethac in for as ymptomatic patent duc tus arterios usin

preterm infants

L ucy C ooke1, P eter A S teer2, P aul G Woodgate1

C itation: C ooke L , S teer P A, Woodgate P G . Indomethacin for asymptomatic patentductus arteriosus in preterm infants . C ochrane D atabase of S ystematic R eviews 2003, Is sue 1. Art. No.: C D003745. DO I: 10.1002/14651858.C D003745.

Main res ults

Three small trials involving a total of 97 infants were included. Metaanalysis of combined data was possible for seven outcomes.Treatment of an asymptomatic PDA with indomethacin significantlyreduced the incidence of symptomatic PDA (R R 0.36, 95% C I 0.19,0.68) and duration of supplemental oxygen (WMD -12.5, 95% C I -23.8

, -1.26). There was no evidence of effect on mortality (R R 1.32, 95%C I 0.45, 3.86), C L D (R R 0.91, 95% C I 0.62, 1.35), IV H (R R 1.21, 95%C I 0.62, 2.37), R O P (R R 0.68, 95% C I 0.26, 1.78), or length ofventilation (WMD -7.00 days , 95% C I -17.33, 3.34). L ong termneurodevelopmental outcomes were not reported. One trial reported asignificant reduction in the duration of supplemental oxygen followingtreatment with indomethacin in the subgroup of infants with birthweight les s than 1000g.


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P rolong ed vers us s hort c ours e ofindomethac in for the treatment of

patent duc tus arterios us in preterminfants

C armen M. H errera1, J ames R Holberton2, P eter G Da vis3

C itation: Herrera C M, Holberton J R , Da vis P G . P rolonged versus s hort cours e ofindomethac in for the treatment of patent ductus arteriosus in preterm infants .C ochrane Database of S ys tematic R eviews 2007, Issue 2. Art. No.: C D003480. DO I:10.1002/14651858.C D003480.pub3.

ConclusionsP rolonged indomethac in course does not appea r to have asignificant effect on improving important outcomes, such as PDA

treatment failure, C L D, IVH, or mortality. T he reduction of trans ientrenal impairment does not outweigh the increas ed risk of NE Cas sociated with the prolonged c ourse. B as ed on thes e results , aprolonged course of indomethacin cannot be recommended for theroutine treatment of P DA in preterm infants .


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Ibuprofen for the treatment of patentduc tus arterios us in preterm and/or lowbirth weig ht infantsArne O hlss on1, R ajneesh Walia2, S achin S S hah3

C itation: Ohlss on A, Walia R , S hah S S . Ibuprofen for the treatment of patent ductus arteriosus in pretermand/or low birth weight infants. C ochrane D atabase of S ystematic R eviews 2008, Iss ue 1. Art. No.:C D003481. DO I: 10.1002/14651858.C D003481.pub3.

C O N C L U S I O NNo statistically significant difference in the effectiveness of ibuprofencompared to indomethacin in clos ing a P DA was found. Ibuprofen comparedwith indomethac in reduces the risk of oliguria and is associated with lowerserum creatinine levels following treatment. P ulmonary hypertens ion hasbeen observed in three infants after prophylactic use of ibuprofen and oneinfant receiving ibuprofen for treatment in this review developed pulmonary

hypertens ion. O ne additional cas e of pulmonary hypertens ion followingtreatment with ibuprofen to close a P DA was identified from the literature.T he available data s upport the us e of either drug for the treatment of a P DA.As both drugs are equally effective in closing a P DA, the c linician needs toweigh the potential side effects of one drug vs. the other when making adecision which drug to use.


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C O N C L U S I O N

PDA causes typical clinical symptoms

clinical diagnosis is not difficult E A R L Y

DIAGNOSIS

The strategies for management continue to

evolve

Transcatheter closure : the treatment of

choice for PDA

P DA in preterm neonates : medical therapy

or surgical ligation


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T H A N K Y O U

T H A N K Y O U

early diagnosis and management of pda

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