Hypertension of the newborn
Ashley S. Ross, M.D.
ANGELS Perinatal Pre
ANGELS Perinatal Pre‐‐Conference
May 5, 2010
shunts (PDA and PFO)
Systemic hypoxia
y yp
Similar to fetal circulation
ryology.ch/anglaais/pcardio/umsteellung01.html
LA
RA
Pulmonary
Foramen Artery
LV
Ovale RV
IVC Ductus
Venosus
http://www.embr
Umbilical Aorta
Vein
h
Umbilical
Placenta Artery
http://www.embbryology.ch/anglais/pcardio/popuupcardio/p9umsttellung/oxygenvoor.html
SVC
Aorta
Pulmonary DA
Artery
LA
RA
IVC LV
LA
Fetal Oxygen Saturations
ryology.ch/anglaais/pcardio/umsteellung02.html
LA
RA
Pulmonary
Patent Artery
LV
Foramen RV
Ovale
IVC Ductus
Venosis
http://www.embr
Umbilical Aorta
Vein
h
Umbilical
Placenta Artery
http://www.embryology.ch/anglais/pcardio/umstellung02.html
http://www.embbryology.ch/anglais/pcardio/popuupcardio/p9umsttellung/oxygennaach.html
SVC
Aorta
Pulmonary DA
Artery
LA
RA
IVC LV
LA
Fetal Oxygen Saturations
z H li
Hyaline membrane disease (RDS)
b di (RDS)
Third most common
Especially in 34‐37 weeks
o Increased pulmonary
Increased pulmonary
vasoreactivity
Hypotension
Acidosis
z Pneumothorax
Hypoxia and/or acidosis
z SSRI’s
Oligohydramnios
o PPROM
Fewer vessels, more reactivity
l
z Lethal forms
Alveolar capillary dysplasia
Surfactant deficiencies
Konduri GG, Kim UO. Advances in the diagnosis and management of persistent pulmonary hypertension of the newborn.
, g g p p y yp
Pediatr Clin North Am. 2009 Jun;56(3):579‐600.
retractions, cyanosis
t ti i
Murmur from tricuspid regurgitation
PDA
z Echocardiography
archildrens.org arpediatrics.org uams.edu
Hyperoxia Test
Hyperoxia Test
z Arterial blood gas obtained prior to and 5‐
g p
10 minutes after administration of 100%
Oxygen
PaO2 < 50 mmHg ‐ cyanotic congenital
heart disease or PPHN
PaO2 <150 mmHg ‐
P O2 150 H PPHN
PaO2 > 150 mmHg ‐ parenchymal lung
disease
PaO2 > 300 mmHg ‐ normal
Prompt treatment and evaluation
homeostasis, blood pressure,
antibiotics
Surfactant
Glucose homeostasis
Electrolyte abnormalities
El t l t b liti
Treat anemia
Follow ABG closely
Low threshold for UAC/UVC
Low threshold for UAC/UVC
Low threshold for ventilation
z Moderate to severe disease must be
treated
treated aggressively
aggressively
archildrens.org arpediatrics.org uams.edu
Treatment
z Goal in moderate to severe disease is
Goal in moderate to severe disease is
to
Reverse right‐to‐left shunts
Reduction of PVR
Reduction of PVR
Maintain systemic blood pressure
Dopamine, dobutamine,
Dopamine dobutamine
epinephrine
o Optimize (not maximize) cardiac
Optimize (not maximize) cardiac
function
Want normal to high blood pressure
Want normal to high blood pressure
Supported by several large trials
Supported by several large trials
Decreased mortality and need for
ECMO
z Milrinone, sildenafil (off label use)
o Not tested in randomized trials
should transfer to ECMO center
ECMO not a replacement for early,
optimized therapy for PPHN
therapy for PPHN