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Cardiac Evaluation of the Newborn

Cardiac Evaluation of the Newborn. Karen D. Sawitz , MD St. Barnabas Hospital Department of Pediatrics. Objectives. To review fetal circulation and understand the changes that take place after birth

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Cardiac Evaluation of the Newborn

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  1. Cardiac Evaluation of the Newborn Karen D. Sawitz, MD St. Barnabas Hospital Department of Pediatrics

  2. Objectives • To review fetal circulation and understand the changes that take place after birth • To differentiate between normal and abnormal cardiac and circulatory function in the first month of life • To discuss the major categories of congenital heart disease that may not present until after nursery discharge and how to evaluate them

  3. Congenital Heart Disease • Incidence of about 1% overall • Even with current prenatal screening practices, not all infants with significant CHD will be identified • Swedish study: 29/60 infants with ductal dependent lesions were not identified prior to nursery discharge

  4. Review of Fetal Circulation - Shunts • Ductusvenosus (umbilical vein to IVC) Carries oxygenated blood from placenta • Foramen ovale (RA to LA) Directs 2/3 of venous return to the left atrium • Ductusarteriosus (pulmonary artery to aorta) Allows 1/3 of venous return to flow to RV and PA for development , protects lungs from overload

  5. Review of Fetal Circulation • Oxygenated blood from placenta enters IVC via ductusvenosus and liver • Blood from IVC enters RA to LA across foramen ovale, then to LV and aorta • Blood from SVC enters RA to RV to PA and across ductusarteriosus to aorta

  6. Postnatal Changes • With first breath, lung pressure dramatically decreases as alveoli open up • Pulmonary blood flow and return to LA increases • Right sided cardiac pressures decrease and left sided pressures increase • Foramen ovale closes due to decreased IVC return and increased pressure in LA • Ductus constricts due to increased PO2 • Continues small Ao to PA shunt for few days, longer if persistent hypoxia

  7. Categories of Congenital Heart Disease

  8. Left Sided Ductal Dependent Lesions

  9. Right Sided Ductal Dependent Lesions

  10. Rhythm Disturbances • Bradyarrythmias • 1st and 2nd degree AV block • Congenital complete AV block • Block due to maternal SLE may take 3-6 months • Tachyarrythmias • Supraventricular tachycardia – often presents in CHF • Ventricular tachycardia • Premature ventricular (and atrial) contractions

  11. Timing of Diagnosis

  12. Reasons for Delayed Diagnosis • Early discharge – lung resistance still high enough to prevent much flow through ASD or VSD so murmur not heard • Delayed PDA closure allows some lung circulation in ductal-dependent lesions • High neonatal hemoglobin may mask cyanosis (requires 5% desaturated hemoglobin) • Birth outside hospital or medical setting • Intermittent symptomatic arrhythmia (SVT)

  13. Manifestations of Cardiac Problems M U R M U R S

  14. CV Evaluation at the Newborn Visit

  15. Maternal History Red Flags • Maternal Diabetes • d-TGA, VSD, Coarctation of the aorta, hypertrophic cardiomyopathy • Maternal Lupus • AV Block, L-TGA, dilated cardiomyopathy • Maternal Alcohol Abuse • VSD, ASD, TOF, Coarctation of the aorta • Maternal Rubella • PDA, PPS, VSD, ASD, arterial abnormality

  16. Syndromic Associations • Down’s Syndrome • 40% with CHD • AV Canal > VSD > ASD > TOF > PDA • Turner Syndrome • Coarctation of the aorta, bicuspid aortic valve, aortic dilatation, dissection and rupture • Noonan Syndrome • 50% of cases: PS, conduction abn, ASD, VSD, TOF, subAS, complex CHD

  17. CV Evaluation at the Newborn Visit

  18. Non-Cardiac Causes of Cyanosis • Respiratory distress syndrome (RDS) • Aspiration eg. meconium • Infection eg. pneumonia • Pneumothorax, pleural effusion • Congenital diaphragmatic hernia • Persistent pulmonary hypertension • Choanalatresia, Pierre-Robin sequence

  19. Murmurs • Left-to-right shunt murmur may be audible in first few days • Hadassah U study: • 20,323 births over 3 years. • Age 1-5 days, 170 babies referred for echo solely on basis of murmur. • 147/170 (86%) had cardiac lesion: VSD (37%), PDA (23%), Both (7%), PS (4%), AS (2%). • 5% had unforeseen complex congenital heart dz

  20. Evaluation of Murmur

  21. Evaluation of Murmur

  22. Case #1 • 4 day old male infant presents to clinic because of decreased feeding, lethargy, poor color, increased work of breathing, • Prenatal history unremarkable, spent 2 days in hospital, no reported problems, discharged 48 hours ago

  23. Case #2 • 3d old male presents to clinic because of poor feeding, comfortable tachypnea, blue when cries, harsh murmur • Pre-natal Hx unremarkable, no U/S done during pregnancy • D/C to home at 26 hrs of life

  24. Case #3 • Infant is tachycardic, 200-220/min, mottled with poor perfusion. Poor feeding. Respirations are labored with rate of 80/min.

  25. Case #4 • 7 day old infant comes to first clinic visit c/o breathing hard, no weight gain since discharge, cold blue feet. • BP in arm higher than leg, has decreased femoral pulses and harsh murmur at the back.

  26. Next Steps • ABCs, ER transfer if acutely ill • Cardiology referral • Studies • Chest X-ray • EKG • Echocardiogram • CBC • Cardiac catheterization

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