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CHAPTER 1 NARRATIVE PATHOLOGY

Several Factors are associated with the incidence of the Congenital Heart Disease (CHD). These include prenatal factors such as poor nutrition of the mothers, maternal inhalation of second hand smoke. Genetic factors are also implicated in CHD as the child has chromosomal aberration specifically Trisomy and as her mother has cardiac problem. The Cardiovascular System is one of the first systems to become functional in intrauterine life. The heart arises from the mesoderm during the first trimester. Thus, this period is considered to be the critical time for heart development. Malformation occurs as the structures of the heart fail to progress beyond an early stage of embryonic development as what happened to the ventricular septum. Originally, the ductus arteriosus and foramen ovale are open at birth and normally close a few months after. After such period, the non-closure of these structures is already considered as defects. Because of the presence of these defects, theres an impaired central pumping mechanism as the peripheral blood follows normal flow through heart and lungs, some blood leaks into the right atrium via Atrial-Septal Defect (ASD), into the right ventricle via Ventricular-Septal Defect (VSD) and into the pulmonary artery via Patent Ductus Arteriosus. The general effects of these heart malformations are summarized as: 1.) Pulmonary Congestion 2.) Cardiac Congestion 3.) Poor tissue perfusion as the oxygenated blood mixed up with non-oxygenated blood Pulmonary Congestion is caused by severe overloading of the right ventricle and occasionally a right atrium causes hypertrophy and obvious cardiac enlargement. Pneumonia and recurrent respiratory infection occur as large amounts of blood pool in the lungs, compromising pulmonary compliance. Pneumonia involves inflammatory response that produces mucosal edema, airway inflammation and increases secretions.

Inflamed and fluid filled alveolar sacs cannot exchange oxygen and carbon dioxide effectivel. Alveolar exudate tends to consolidate, so it is increasingly difficult to expectorate. Moreover, inflammation of airways produced shortness of breath and chest tightness, leading to pain. Fever also occurs in association with Pneumonia. Dyspnea also occurs from increased pulmonary resistance as the lungs are unable oxygenate adequate supplies of bloodnoted as impaired gas exchange, resulting in air hunger. It may be associated with tachypnea or hyperventilation as the lungs try to compensate through an increase respiratory effect. Cardiac Congestion occurs as the myocardium of the heart cannot pump and circulate enough blood to supply oxygen and nutrients to body cells. Due to leakage, theres decrease in venous return; and consequently, the contraction of the heart weakens, producing decrease in cardiac output. As a result, mottling or pallor is noted as inadequate blood reaches the systemic circulation. The heart compensates to move blood forward and attempt to increase cardiac output. The heart exerts an extra effort by increasing the number of beats per minute or by pumping twice or more as usual, increasing the workload of the heart. However, the capacity of the heart for compensation is limited. Eventually, the heart can no longer compensate and become overwhelmed by the amount of blood present which cannot be pushed forward effectivelycausing cardiac overload and consequently death. Poor tissue perfusion, which is characterized by inadequate arterial blood saturation, leads to manifestation of signs and symptoms namely anemia, decrease activity intoleranceduring feedings when the infant is too fatigue to prolong the feeding, stress-induced cyanosisis the result of the oxygenated haemoglobin in the skin blood vessels, especially in the capillaries; Any event that increases metabolism and thus causes demand for additional oxygen may result in a more severe degree of cyanosis and clubbing of fingers. Persistent hypoxia results in tissue changes anywhere in the body. Moreover, malabsorption of nutrients by the intestines occurs. This leads to retarded physical growth and development characterized by failure to gain weight, increase height, presence of head lag, and unable to turn front to back, inability to hold head up when prone and unable to bear partial weight on feet when upright. This also leads to

malformation like immature internal organs and clubbing. In order to cope up with these disruptions the body initiates some internal coping mechanism. For instance, the circulatory system would increase venous return and eventually leads to cardiac overload. The respiratory system initiates hyperventilation and eventually leads to respiratory distress. There would be sodium retention in the renal system that would eventually precipitate renal failure. If these complications are not treated, multiple organ failure occurs, leading to death. Medical interventions should be done in order to prevent further complications. Closure of the defects through surgical interventions would return the normal central circulatory function resulting to increase tissue perfusion, cardiac decongestion and pulmonary decongestion. Medications are given to alleviate certain abnormalities. Digitalis is administered to increase cardiac contractionas the leakage of blood via the defects reduces venous return and consequently weakens the cardiac contraction. Diuretics act on the renal system to facilitate sodium excretionto counteract the internal coping mechanism of the kidney. Antibiotics are administered to fight infection. Paracetamol is given to relieve fever and pain. Salbutamol is given to dilate the bronchioles thus achieving airway clearance.