early diagnosis and management of pda
TRANSCRIPT
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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