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Management of Patent Ductus Arteriosus in Premature Infants

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Abstract

Patency of the ductus arteriosus is required for fetal survival in utero. In infants born prematurely, ductus fails to close and shunt reverses from left to right. Incidence of patent ductus arteriosus (PDA) is inversely proportional to the gestational age. A large PDA (>1.5 mm diameter) with left to right shunt in very low birth weight infants can cause pulmonary edema, congestive heart failure, pulmonary hemorrhage and increase the risk for bronchopulmonary dysplasia. Attempts to prevent or close the duct by pharmacological or surgical methods have not changed the morbidity or the long term outcome. Pharmacological treatment with indomethacin or ibuprofen is successful in 75 to 80 % of infants but its use also exposes these infants to undesirable side effects like gastrointestinal bleeding, perforation and necrotizing enterocolitis. Prophylactic therapy with indomethacin or ibuprofen to prevent PDA has not altered the morbidity or long term outcome. Currently, there is a dilemma as to how to treat, when to treat and whom to treat. Recent literature suggests a trial of conservative management during the first week followed by selective use of anti-inflammatory drugs. Surgical ligation is reserved for infants who fail medical therapy and still remain symptomatic. Spontaneous closure of the PDA has been reported in up to 40–67 % of very low birth weight (VLBW) infants by 7 d. In this review authors discuss these controversies and propose a more rational approach.

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References

  1. Arcilla RA, Thilenius OG, Ranniger K. Congestive heart failure from suspected ductal closure in utero. J Pediatr. 1969;75:74–8.

    Article  CAS  PubMed  Google Scholar 

  2. Clyman RI. Mechanisms regulating the ductus arteriosus. Biol Neonate. 2006;89:330–5.

    Article  PubMed  Google Scholar 

  3. Brown RE. Increased risk of bronchopulmonary dysplasia in infants with patent ductus arteriosus. J Pediatr. 1979;95:865–6.

    Article  CAS  PubMed  Google Scholar 

  4. Evans N, Kluckow M. Early ductal shunting and intraventricular hemorrhage in ventilated preterm infants. Arch Dis Child Fetal Neonatal Ed. 1996;75:F183–6.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  5. Benitz WE. Treatment of persistent patent ductus arteriosus in preterm infants: time to accept the null hypothesis? J Perinatol. 2010;30:241–52.

    Article  CAS  PubMed  Google Scholar 

  6. Nemerofsky SL, Parravicini E, Batemean D, Kleinman C, Polin RA, Lorenz JM. The ductus arteriosus rarely requires treatment in infants >1000 grams. Am J Perinatol. 2008;25:661–6.

    Article  PubMed  Google Scholar 

  7. Koch J, Hensley G, Roy L, Brown S, Ramaciotti C, Rosenfeld CR. Prevalence of spontaneous closure of the ductus arteriosus in neonates at a birth weight of 1000 grams or less. Pediatrics. 2006;117:1113–21.

  8. Kaempf JW, Huston R, Wu YX, Kaempf AJ, Wang L, Grunkemeier G, et al. Permissive tolerance of the patent ductus arteriosus may increase the risk of chronic lung disease. Res Rep Neonatol. 2013;3:5–10.

    Article  Google Scholar 

  9. Rajadurai VS, Yu VYH. Intravenous indomethacin therapy in preterm neonates with patent ductus arteriosus. J Paediatr Child Health. 1991;27:370–5.

    Article  CAS  PubMed  Google Scholar 

  10. Del Moral T, Gonzalez-Quintero VH, Claure N, Vanbuskirk S, Bancalari E. Antenatal exposure to magnesium sulfate and the incidence of patent ductus arteriosus in extremely low birth weight infants. J Perinatol. 2007;27:154–7.

    Article  Google Scholar 

  11. Gonzalez A, Sosenko IRS, Chander J, Hummler H, Claure N, Bancalari E. Influence of infection on patent ductus arteriosus and chronic lung disease in premature infants weighing 1000 grams or less. J Pediatr. 1996;128:470–8.

  12. Bell EF, Acaregui MJ. Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2008;1:CD000503.

    PubMed  Google Scholar 

  13. Rosenfeld W, Sadhev S, Brunot V, Jhaveri R, Zabaleta I, Evans HE. Phototherapy effect on the incidence of patent ductus arteriosus in premature infants with chest shielding. Pediatrics. 1986;78:10–4.

    CAS  PubMed  Google Scholar 

  14. Dudell GG, Gersony WM. Patent ductus arteriosus in neonates with severe respiratory disease. J Pediatr. 1984;104:915–20.

    Article  CAS  PubMed  Google Scholar 

  15. Dagle JM, Lepp NT, Cooper ME, Schaa KL, Kelsey KJ, Orr KL, et al. Determination of genetic predisposition to patent ductus arteriosus in preterm infants. Pediatrics. 2009;123:1116–23.

    Article  PubMed Central  PubMed  Google Scholar 

  16. Razka T, Magnenant E, Klosowski S, Tourneux P, Bachiri A, Storme L. Early hemodynamic consequences of patent ductus arteriosus in preterm infants with intrauterine growth restriction. J Pediatr. 2007;151:624–8.

    Article  Google Scholar 

  17. Hemrick SEG, Hansman G. Patent ductus arteriosus of the preterm infant. Pediatrics. 2010;125:1020–30.

    Article  Google Scholar 

  18. Clyman RI, Seidner SR, Kajino H, Roman C, Koch CJ, Ferrara N, et al. VEGF regulates remodeling during permanent anatomic closure of the ductus arteriosus. Am J Physiol Regul Integr Comp Physiol. 2002;282:R199–206.

    CAS  PubMed  Google Scholar 

  19. Echtler K, Stark K, Lorenz M, Kerstan S, Walch A, Jennen L, et al. Platelets contribute to postnatal occlusion of the ductus arteriosus. Nat Med. 2010;16:75–82.

    Article  CAS  PubMed  Google Scholar 

  20. Shah NA, Hills NK, Welch N, McCurnin D, Seidner S, Chemtob S, et al. Relationship between circulating platelet counts and ductus arteriosus patency after indomethacin treatment. J Pediatr. 2011;158:919–23. e1-2.

    Article  PubMed Central  PubMed  Google Scholar 

  21. Bhat R, Malalis L, Shukla A, Vidyasagar D. Colloid osmotic pressure in infants with hyaline membrane disease. Chest. 1983;83:776–9.

    Article  CAS  PubMed  Google Scholar 

  22. Stefano JL, Abbasi S, Pearlman SA, Spear ML, Esterly KL, Bhutani VK. Closure of the ductus arteriosus with indomethacin in ventilated neonates with respiratory distress syndrome. Effects of pulmonary compliance and ventilation. Am Rev Respir Dis. 1991;143:236–9.

    Article  CAS  PubMed  Google Scholar 

  23. Strauss T, Pessach I, Jacoby E, Schushan-Eisen I, Mazkereth R, Kuint J. Carina angle measurements for diagnosis of patent ductus arteriosus in preterm infants. Neonatology. 2011;99:2214–30.

    Article  Google Scholar 

  24. Khositseth A, Muangyod N, Nuntnarumit P. Perfusion index as a diagnostic tool for patent ductus arteriosus in preterm infants. Neonatology. 2013;104:250–4.

    Article  PubMed  Google Scholar 

  25. Evans N, Malcolm G, Osborn D, Kluckow M. Diagnosis of patent ductus arteriosus in preterm infants. Neo Rev. 2004;5:e86–97.

  26. Kluckow M, Evans N. Early echocardiographic prediction of symptomatic patent ductus arteriosus in preterm infants undergoing mechanical ventilation. J Pediatr. 1995;127:774–9.

    Article  CAS  PubMed  Google Scholar 

  27. Choi BM, Lee KH, Eun BL, Yoo KH, Hong YS, Son CS, et al. Utility of rapid B –natriuretic peptide assay for diagnosis of symptomatic patent ductus arteriosus in preterm infants. Pediatrics. 2005;115:e255–61.

    Article  PubMed  Google Scholar 

  28. El-Khuffash A, Barry D, Walsh K, Davis PG, Molloy EJ. Biochemical markers may identify preterm infants with a patent ductus arteriosus at high risk of death or severe intraventricular hemorrhage. Arch Dis Child Fetal Neonatal Ed. 2008;93:F407–12.

    Article  CAS  PubMed  Google Scholar 

  29. Saldeno YP, Favareto V, Mirpuri J. Prolonged persistent patent ductus arteriosus: potential perdurable anomalies in preterm infants. J Perinatol. 2012;32:953–8.

    Article  CAS  PubMed  Google Scholar 

  30. Bhat R, Fisher E, Raju TNK, Vidyasagar D. Patent ductus arteriosus: recent advances in diagnosis and management. Pediatr Clin North Am. 1982;29:1117–36.

    CAS  PubMed  Google Scholar 

  31. Clyman R, Wickremasinghe A, Jhaveri N, Hassinger DC, Attridge JT, Sanocka U, et al; Ductus Arteriosus Feed or Fast with Indomethacin or Ibuprofen (DAFFII) Investigators. Enteral feeding during indomethacin and ibuprofen treatment of patent ductus arteriosus. J Pediatr. 2013;163:406–11.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  32. Fowlie PW, Davis PG. Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants. Evid Based Child Health. 2010;5:416–71.

    Article  Google Scholar 

  33. Schmidt B, Davis P, Moddemann D, Ohlsson A, Roberts RS, Saigal S, et al. Long- term effects of indomethacin prophylaxis in extremely low birth weight infants. N Engl J Med. 2001;344:1966–72.

    Article  CAS  PubMed  Google Scholar 

  34. Ohlsson A, Shah SS. Ibuprofen for the prevention of patent ductus arteriosus in preterm and or low birth weight infants. Cochrane Database Syst Rev. 2006;7:CD004213.

  35. Tschuppert S, Doell C, Arlettaz-Mieth R, Baenziger O, Rousson V, Balmer C, et al. The effect of ductal diameter on surgical and medical closure of patent ductus arteriosus in preterm neonates: size matters. J Thorac Cardiovasc Surg. 2008;135:78–82.

    Article  PubMed  Google Scholar 

  36. Aikio O, Harkin P, Saarela T, Hallman M. Early paracetamol treatment associated with lowered risk of persistent ductus arteriosus in very preterm infants. J Matern Fetal Neonatal Med. 2013. doi:10.3109/14767058.2013.854327.

    PubMed  Google Scholar 

  37. Oncel MY, Yurttutan S, Degirmencioglu H, Uras N, Altug N, Erdeve O, et al. Intravenous paracetamol treatment in the management of patent ductus arteriosus in extremely low birth weight infants. Neonatology. 2013;103:166–9.

    Article  CAS  PubMed  Google Scholar 

  38. Moin F, Kennedy KA, Moya FR. Risk factors predicting vasopressor use after patent ductus arteriosus ligation. Am J Perinatol. 2003;20:313–20.

    Article  PubMed  Google Scholar 

  39. Smith ME, King JD, Elsherif A, Muntz HR, Park AH, Kouretas PC. Should all newborns who undergo patent ductus arteriosus ligation be examined for vocal fold mobility? Laryngoscope. 2009;119:1606–9.

    Article  PubMed  Google Scholar 

  40. Shelton JE, Julian R, Walburgh E, Schneider E. Functional scoliosis as a long term complication of surgical ligation of patent ductus arteriosus in premature infants. J Pediatr Surg. 1986;21:855–7.

    Article  CAS  PubMed  Google Scholar 

  41. Chorne N, Leonard C, Piecuch R, Clyman RI. Patent ductus arteriosus and its treatments risk factors for neonatal and neurodevelopmental morbidity. Pediatrics. 2007;119:1165–74.

    Article  PubMed  Google Scholar 

  42. Hines MH, Raines KH, Payne RM, Covitz W, Cnota JF, Smith TE, et al. Video - assisted ductal ligation in preterm infants. Ann Thorac Surg. 2003;76:1417–20.

    Article  PubMed  Google Scholar 

  43. McNamara PJ, Sehgal A. Towards the rational management of patent ductus arteriosus: the need for disease staging. Arch Dis Child Fetal Neonatal Ed. 2007;92:F424–7.

    Article  PubMed Central  PubMed  Google Scholar 

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Correspondence to Rama Bhat.

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Bhat, R., Das, U.G. Management of Patent Ductus Arteriosus in Premature Infants. Indian J Pediatr 82, 53–60 (2015). https://doi.org/10.1007/s12098-014-1646-6

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  • DOI: https://doi.org/10.1007/s12098-014-1646-6

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