Patent ductus arteriosus

Diagnosis

1. Early: Mostly silent, with no murmur. BP may be low (systolic, diastolic and mean) with normal pulse pressure.
1. Late: Murmur. Hyperactive precordium. 2. Increased pulses. Wide pulse pressure. These are not reliable signs in the first few days. 3. Congestive Heart Failure 1. Cardiomegaly 2. Hepatomegaly 3. Pulmonary congestion/oedema/plethora 4. Clinical respiratory deterioration. 5. Rising PaCO2. Investigations Echocardiogram

1. Usually done at 3 days in infants <28 weeks' gestation or <1000g. 2. Other babies are investigated on clinical suspicion.
-Rules out (most) congenital heart disease. -It is important to rule out duct dependent lesions, especially coarctation.

3. Establishes ductal patency and size.

4. Indicates the size of the shunt (ductus shunt is best assessed by its physical size, then by descending aortic flow pattern).

a) A ductal lumen >1.5mm and a reversed descending aortic diastolic flow suggest a significant PDA. b) Left pulmonary artery flow may be useful. c) Left atrial:Aortic root ratios and LV size are less helpful. d) Assesses atrial shunt and size.

Management Indications for treatment <28 weeks or <1000gms, and 1. 2. 1. Significant shunt in a small baby with ongoing lung disease. 2. Closure of the ductus is aimed mainly at improving lung function. Echocardiogram at 3 days. Significant PDA: Consider Ibuprofen

on IPPV or CPAP

Ibuprofen is a drug of choice for the treatment of PDA Initially 10mg/kg as a single dose followed at 24 hours intervals by two doses of 5 mg/kg. Can be repeated after 48 h of the last dose if necessary. Infuse over 30 minutes. Side effects:
1. Monitor creatinine, electrolytes, urine output & platelets before and at least daily initially. If these parameters remain normal, then they do not need to be routinely checked after the 3rd dose. 2. Review baby and results before each dose. Contraindications: Thrombocytopenia NEC Bleeding diathesis Poor renal function Pulmonary haemorrhage (note: may occur because there is a PDA) Fluid restriction There is no evidence that fluid restriction per se results in closure of the duct but there are studies suggesting that early, liberal fluid intakes are associated with a higher incidence of PDA. Surgery - If PDA is still clinically significant after ibuprofen or if ibuprofen is contraindicated. - Surgery will be required