Fetal Circulation

SIRKULASI DARAH JANIN

(Fetal circulation)
 Sirkulasi darah pada janin tidak sama dengan sirkulasi
darah pada bayi, anak maupun orang dewasa.
 Pada janin organ2 vital untuk fungsi metabolism tubuh
belum berfungsi. Organ yang dimaksud adalah paru paru
dan sistim gastrointestinal.
 Organ tersebut diatas diambil alih oleh plasenta

 Terjadi pergantian O2 dan CO2 di plasenta sehingga

paru2 pada hakekatnya tidak memerlukan darah.
 Demikian pula system gastrointestinal sebagai alat
penyerapan nutrisi belum berfungsi.
 PERBEDAAN SIRKULASI DARAH INTRA UTERIN DAN
EKSTRA UTERINE

1. Aliran darah arteri pulmonalis dari ventrikel kanan

menuju aorta melalui arteri ductus Botalli.
2. Darah dari vena umbilical melalui hepar langsung
menuju vena kava inferior melalui ductus venosus
Arantii.
3. Darah dari vena cava inferior menuju jantung
sebagian langsung menuju atrium kiri melewati
foramen ovale.
4. Kemudian sebagian ke ventrikel kiri dan selanjutnya
ke aorta.
CONGENITAL HEART DISEASE

Atrial Septal Defect (ASD)

Ventricular Septal Defect (VSD)
 ATRIAL SEPTAL DEFECT (ASD)
Prevalence. 5% to 10% of all CHDs. Female preponderance (male-
to-
female ratio of 1:2.
Pathology and Pathophysiology.

 Three types of ASD occur in the atrial septum :

o Secundum ASD is in the central portion of the septum (50%-

70%).
o Primum ASD is in the lower part of the septum (30%).
o Sinus venosus defect is near the entrance of the SVC or IVC to
the
right atrium (10%).
Clinical manifestations.

1. The patients are usually asymptomatic.

2. A widely split and fixed S2 and a grade 2 to 3/6 systolic ejection
murmur at the ULSB.
3. The ECG shows RAD (+ 90 to + 180 degrees) and mild RVH or
RBBB.
4. CXR films show cardiomegaly (with RA enlargement and RV
enlargement).
5. Two-dimensional echo shows the position and the size of the
defect.
Cardiac catheterization is usually not necessary.
6. Spontaneous closure of the defect occurs more than 80% (3-8
mm).
An ASD with diameter > 8 mm (by echo) rarely closes
spontaneously
Management

1. Exercise restriction is not required.

2. Nonsurgical closure of the defect using a catheter – delivered
closure device has become a preferred method. This devices
are applicable only to secundum ASD.
Following the device closure, the patients are placed on
aspirin 81
mg/day for 6 months.
3. Surgical.: For patients with primum ASD and sinus venosus
defect, and for secundum ASD for which the device closure in
considered inappropriate.

Post surgical follow-up .: Atrial and nodal arrhythmias occur

in 7%
to 20% od patients. Occasional sick sinus syndrome (SSS)
 Ventricular Septal Defect (VSD)
Prevalence. VSD is the most common form of CHD,
accounting for 15% to 20% of all CHDs.

Pathology and Pathophysiology.

1. VSD consist of a small membranous septum and a larger
muscular
septum. The muscular septum has three components; the
inlet,
infundibular, and trabecular septa.
2. The perimembranous VSD is more common (70%) than the
trabecular (5% to 20%), infundibular (5% to 7%), or inlets
defect
(5% to 8%).
3. The perimembranous VSD is frequently associated with PDA
Clinical manifestation.
1. Patients with VSDs are symptomatic, with normal growth and
development. With large VSDs, delayed growth and
development, repeated pulmonary infections, CHF, and
decrease exercise tolerance are relatively common.
2. With small VSD, a grade 2 to 5/6 regurgitant systolic murmur
(holosystolic) maximally audible at the LLSB. A systolic thrill
may be present at the LLSB. With a large defect, an apical
diastolic rumble is audible, which represents a relative stenosis
of mitral valve due to large pulmonary venous return to LA.
The S2 may split narrowly , and the intensity of the P2
increases if pulmonary hypertension is present.
3. ECG findings : small VSD, normal; moderate VSD, LVH and
LAH; large VSD, biventricular hypertrophy (BVH)
Management.
Medical. Treatment CHF with digitalis, and diuretics. No exercise
restriction is required in the absence of pulmonary hypertension
(PH).

Surgical.
1. Direct closure of the defect is performed under cardiopulmonary
bypass and/or deep hypothermia.
2. Indication and timing.
a. A significant L-R shunt with Qp/Qs of greater than 2:1 is
indication
for surgical closure. Surgery is not indicated for a small VSD
with
Qp/Qs less than 1.5:1.
b. Infants with CHF and growth retardation unresponsive to
medical