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Patent Ductus Arteriosus

Patent Ductus Arteriosus. Incidence of PDA. Closure of PDA in term infants: 50% by 24 hours 90% by 48 hours 100% by 72 hours Closure of PDA >30 weeks gestation: 11% remain open after 4 days Closure of PDA < 30 weeks gestation: 65% remain open after 4 days. Regulation of Ductal Closure.

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Patent Ductus Arteriosus

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  1. Patent Ductus Arteriosus

  2. Incidence of PDA • Closure of PDA in term infants: • 50% by 24 hours • 90% by 48 hours • 100% by 72 hours • Closure of PDA >30 weeks gestation: • 11% remain open after 4 days • Closure of PDA < 30 weeks gestation: • 65% remain open after 4 days

  3. Regulation of Ductal Closure • Functional closure of lumen: • Occurs within hours after birth due to smooth muscle constriction • Anatomic occlusion of lumen: • Occurs days after birth due to intimal thickening and loss of smooth muscle cells

  4. Factors regulating Ductal Relaxation • Increased pulmonary vascular pressure • Vasodilator prostaglandins: PGE1 • Nitric oxide

  5. Post-natal factors regulating Ductal Closure • Increased Pa02 • Decreased PVR • Decreased circulatory concentrations of PGE1 • Decreased PGE1 receptors in ductal wall • Increased cortisol concentrations

  6. Factors Restricting Ductal Closure in Preemies • Decreased intrinsic smooth muscle tone • Higher circulating PGE1 concentrations • Increased sensitivity to vasodilatory effects of PGE1 and NO

  7. Hemodynamic and Pulmonary Consequences of PDA • Left to right shunt: increased pulmonary venous pressure, increased pulmonary edema • Decreased blood flow to skin, bone, muscle, GI tract, and kidneys • Rapid increase in pulmonary blood flow leading to pulmonary hemorrhage (risk of surfactant administration)

  8. Treatment • Indocin prophlaxis • Treatment indocin: closure in 85% patients • Surgical ligation

  9. Complications of PDA • BPD • NEC • Feeding intolerance

  10. Risks of Indocin Use • Decreased mesenteric, renal, and cerebral blood flow • Oliguria, dilutional hyponatremia • Isolated intestinal perforation (increased risk when combined with postnatal steroids) • NEC?

  11. Contraindications to Indocin Use • NEC • Renal failure • Bleeding disorders and severe thrombocytopenia • Hemodynamically insignificant PDA

  12. Clinical diagnosis • Systolic heart murmur, though may be absent • Hyperdynamic precordium • Bounding peripheral pulses • Wide pulse pressure • Worsening respiratory status

  13. Indocin Prophylaxis • Decreases symptomatic PDA and the need for surgical ligation • Decreases Grade III and IV IVH • No change in short or long term mortality • No difference in rates of NEC • Long term neurodevelopmental outcome is not adversely affected

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