ARBA MINCH UNIVERSITY

COLLEGE OF MEDICINE AND HEALTH SCIENCE

DEPARTMENT OF NURSING
POST GRADUATE IN MATERNITY AND RH NURSING
By: Markos Makisha
ID no:PRMHS/045/13

PERSISTENT FETAL
CIRCULATION
29/03/2023 BY MARKOS MAKISHA
 fetal Circulation

Temporary structure
a) Umblical vein

b) Ductus vensosus
c) Formen ovale ( oval opening)
d) Ductus arteriosus

e) Hypogasteric aretries

29/03/2023 BY MARKOS MAKISHA 2

 Cont…
 Pair of umbilical arteries carry deoxygenated blood and wastes to placenta.
 Umbilical vein carries oxygenated blood and nutrients from the placenta.

29/03/2023 BY MARKOS MAKISHA 3

Cont…

29/03/2023 BY MARKOS MAKISHA 4

The structural changes which happens after delivery

29/03/2023 BY MARKOS MAKISHA 5

 Cont…

Foramen ovale Closes shortly after birth, fuses completely in

first year (fossa ovalis)

Ductus Closes soon after birth, becomes ligamentum

arteriousus arteriousum in about 3 month

Ductus venosus Ligamentum venosum

Umbilical arteries Medial umbilical ligaments

Umbilical vein Ligamentum teres

29/03/2023 BY MARKOS MAKISHA 6

 Transitional circulation
Interruption of Umbilical cord
Removal of the low resistance placental circulation result in
an Increased systemic vascular resistance
lack of blood flow through the placenta leads to closure of
Ductus venosus (the ligamentum venosum)

29/03/2023 BY MARKOS MAKISHA 7

 Cont…
• Expansion of lungs : Mechanical expansion of the
lungs and increased arterial P02 result in a rapid
decrease in pulmonary vascular resistance. The
increased blood volume from the pulmonary
circulation increased the LA volume and pressure
sufficiently to close the foramen ovale (fossa
ovalis)
• DA closure : The ductus flow become left to right
and later the ductus will obliterated.(ligamentum
arteriosus)
29/03/2023 BY MARKOS MAKISHA 8
 Congenital Heart disease
• Is Structural or functional heart disease that present at
birth. Abnormalities of the heart or great vessels that
are present from birth

• Most such disorders arise from faulty embryogenesis

during gestational weeks 3 through 8, when major
cardiovascular structures develop.

• The most severe anomalies may be incompatible with

intrauterine survival.
29/03/2023 BY MARKOS MAKISHA 9
 Frequencies of Congenital Cardiac Malformations

29/03/2023 BY MARKOS MAKISHA 10

 Etiology
• The cause of most congenital heart disease is
unknown
• Most cases of congenital heart disease were
thought to be multifactorial and result from a
combination of genetic predisposition and
environmental stimulus
• Specific aetiology only known 10%
• 8% genetic
• 2% environmental (rubella, foetal-alcohol
syndrome)
29/03/2023 BY MARKOS MAKISHA 11
 Classification of Congenital Heart Disease
• Two types:
– ACYANOTIC CONGENITAL HEART
LESIONS
• Volume overload
• Pressure overload
– CYANOTIC CONGENITAL HEART
LESIONS
• Decrease blood flow to the lung
• Increase blood flow to the lung

29/03/2023 BY MARKOS MAKISHA 12

 CHD cont…
The varied structural anomalies in congenital heart
disease fall primarily into three major categories:

   •    Malformations causing a left-to-right shunt

   •    Malformations causing a right-to-left shunt

   •    Malformations causing an obstruction.

29/03/2023 BY MARKOS MAKISHA 13

29/03/2023 BY MARKOS MAKISHA 14
Common Congenital Heart Diseases

cyanosis
Acynotic
• TOF
Shunts ( L to R) :
• TGA
• ASD
• VSD
• Tricuspid atresia
• PDA • Truncus
• AVSD • TAPVR
Stenosis: • Ebstein’s
• AS • Single ventricle eg.
• PS HLHS
• Coarctation

29/03/2023 BY MARKOS MAKISHA 15

 1) a cyanotic heart disease
Left-to-right shunts
• Atrial septal defect (ASD), ventricular septal defect (VSD), and
patent ductus arteriosus [PDA]

• Increase pulmonary blood flow and are not initially associated with
cyanosis (called acyanotic congenital HD).

• Expose the postnatal, low-pressure, low-resistance pulmonary

circulation to increased pressure and/or volume, which can result in
right ventricular hypertrophy and, potentially, failure.

– Shunts associated with increased pulmonary blood flow include ASDs;

– shunts associated with both increased pulmonary blood flow and pressure
include VSDs and PDA.
29/03/2023 BY MARKOS MAKISHA 16
 a cyanotic cont …

Defect with increased pulmonary blood flow

–ASD
–VSD
–PDA
–AV canal defect
Obstruction to flow from ventricles
–CO Aorta
–Pulmonary stenosis
–Aortic stenosis
29/03/2023 BY MARKOS MAKISHA 17
a cyanotic cont …

VSD Most common

congenital cardiac
anomaly.
• Frequently, VSD is
associated with other
structural defects, such as
tetralogy of Fallot.
• Defect in the
membranous
interventricular septum
• Most spontaneously close

29/03/2023 BY MARKOS MAKISHA 18

Atrial septal defect (ASD)
• Don’t confuse it with patent foramen ovale
(present in 1/3rd of adult population)
• Associated with fetal alcohol syndrome
• Increased SaO2 in right atrium, right ventricle
and pulmonary artery
• Secundum ASD (90%)
– defect located at and resulting from a deficient or
fenestrated oval fossa.
• Primum ASD (5% of ASDs)
– Defect occur adjacent to the AV valves and are
usually associated with a cleft anterior mitral leaflet.
– This combination is known as a partial AV septal
defect.
• Sinus venosus defects (5%) are located near the
entrance of the superior vena cava.

29/03/2023 BY MARKOS MAKISHA 19

Cont…

20
 Malformations causing obstruction

• Coarctation of the aorta (CoA),

aortic valvular stenosis, and
pulmonary valvular stenosis

• Produce obstructions to flow

because of abnormal narrowing
of chambers, valves, or blood
vessels (called obstructive
congenital HD).
29/03/2023 BY MARKOS MAKISHA 21
 2) cyanotic heart disease

Decreased pulmonary blood flow

–Tricuspid atresia
–Tetralogy of fallot
Mixed blood flow
–Trans position of great vessels
–Hypo plastic left heart syndrome

29/03/2023 BY MARKOS MAKISHA 22

 Right-to-left shunt
• When blood from the right side of the heart enters the left
side
• Diminished pulmonary blood flow
• Poorly oxygenated blood enters the systemic circulation
(called cyanotic congenital heart disease).
Examples
• Tetralogy of Fallot,
• Transposition of the great arteries,
• Persistent truncus arteriosus,
• Tricuspid atresia, and
• Total anomalous pulmonary venous connection.
29/03/2023 BY MARKOS MAKISHA 23
 Management
Medical management:

A) Neonatal period if pulmonary flow is dependent of DA, give

prostaglandin to prevent ductal closure and followed by palliative
shunt (B-T Shunt)
B)Recognition and treatment of hyper cyanotic spell.
Knee chest positioning of the patient
Administration of oxygen
Volume expansion
Correction of acidosis
Sedation with morphine
Propranolol
C) Treat infective endocarditis
D) Anaemia should be corrected
E) Severe polycythemia correction with phlebotomy should be done.
 Management

Surgical Management:
A) Palliative: Modified Blalock-Taussig shunt
between pulmonary artery branch and
subclavian artery
B) Corrective surgery : closing of the VSD and
reliving all possible source of RVOT
obstruction.
 Clinical manifestation of CHD
CHD suspected in any child with:
• Feeding difficulty
• Recurrent attack of respiratory tract infection
• Growth failure
• Cyanosis unresponsive to 100% oxygen
• Tachycardia
• Respiratory distress
• Rhythm disturbance
• Murmur ( absence of murmur doesn't rule out or in
CHD)

29/03/2023 BY MARKOS MAKISHA 26

 Management of CHD
General principle
• 1) Treatment of Congestive Heart Failure
 Diuretics
 Inotropic support
 After load reduction
 2) Correction of underlying defect (timing depend
on the type and severity
• 3)Prevention and treatment of complication
 Pulmonary HPT : early surgical correction
 Infective endocarditis: Administration of antibiotic
chemoprophylaxis as indicated.
 Non infective thromboembolism : prevent polycythemia
 polycythemia :partial exchange transfusion
 Counselling of parents on the risk of recurrence

29/03/2023 BY MARKOS MAKISHA 27

 Nursing care for neonates and children with congenital heart
defects

• •Head to toe P/E

• •Frequent vital signs
• •Timely evaluate cyanosis ,Oxygen therapy and its adjustment
• •Medication administration
• •Feeding and educating mother how to feed
• •Prepare for surgery ,pre and post operative care
• •Sterile wound care
• •Health education of mothers and care givers
• •Monitor input and out put

29/03/2023 BY MARKOS MAKISHA 28

 Cont..

• Thermoregulation
•Kangaroo mother care
•Fluid and electrolyte preparation and monitoring.
•NGT,IV line insertion and frequent follow –up
•Monitoring blood glucose level
•Phototherapy ,incubator and radiant heater
monitoring and adjustment
•Wait measurement and frequent positioning
29/03/2023 BY MARKOS MAKISHA 29
 Thank you!

29/03/2023 30