Transcript
Perinatal meeting Dr Jancy Dr Eman
Dr Prakash.I Dr Sameer
Perinatal management of congenital heart
defect
Birth History Delivered by elective section
Cried at birth
APGAR Score 7 and 8 at 1 and 5 min respectively
Needed intubation at 30 minute of life in NICU
On admission to NICU Growth Parameters: Weight: 2.85kg, Height:48 cm, Head
Circumference: 33.5 cm
Vital signs: Temperature: 36.6’C, Pulse Rate: 168bpm, VRR: 55/min, Blood pressure: 88/47 mmHg ,MAP: 60 mmHg, Oxygen Saturation: pre ductal 60%, post ductal 35%
General Examination: Cyanosed, poor perfusion Examination of Systems: Chest: good air entry bilaterally
CVS: systolic murmur +nt, hyper dynamic precordium
Abdomen: Soft, no organomegaly
Baby on mechanical ventilation, with guarded general condition
Preductal saturation 60%, Postductal saturation 40%
Abnormal movement within 2 hrs, so anticonvulsant was given.
IV antibiotics started (septic screening done)
Investigations: WBC: 16.8, Hb: 17.2 gm%, HCT: 52.4, PLT: 227Blood culture: SterileCXR :……….
Pediatric cardiology consult was taken
2D ECHO done
Inj Prostaglandin E1 started
Transferred to SKMC for further management
At SKMCOn day 2 –surgical repair was done
SpO2: 60-70s
BP: borderline
Deteriorated further on day 3 and died on day 3
Congenital heart defect
Prevalence of CHD: at birth -6 to 13 /1000 live birth
Most common: Acyanotic: muscular and perimembranous
VSD, secundum ASD. Cyanotic: TOF
Preterm > Term babies (2-3 times )
Critical CHD: require surgery or invasive intervention in the 1st yr of life
Critical CHD: 25% of those with CHD
Time of presentation Prenatally During birth hospitalization
Maternal risk factors
Maternal diabetes Maternal obesity Maternal hypertension Maternal CHD(family history) Maternal thyroid conditions Maternal drugs intake Smoking in 1st trimester
Congenital infections: CMV, herpes virus, rubella, coxsackie virus
Drugs in pregnancy: hydantoin, lithium alcohol
Assisted reproductive technology (outflow tracts and ventriculoarterial connections)
Congenital complete heart block: maternal connective tissue disorder, anti-Ro/SSA and anti- La/SSB
Family history 1st degree relative has CHD: 3 fold increase
risk
Familial risk of specific malformations is even greater, suggesting stronger genetic effect in these conditions
Relative risk for monozygotic twins:15.2 Dizygotic twins: 3.3
Risk in singletons birth with 1st,2nd or 3rd degree relatives with CHD was 3.2,1.8 or 1.1 respectively
PRENATAL USSSensitivity of prenatal screening range from
0-80% detection rates
Sensitivity depends on: GA, maternal weight, fetal position and type of defect
Early serious or life threatening presentation Shock : differentiate with sepsis as a cause. Cardiomegaly is
common finding Cyanosis
Reduced Hb 4-5gm% Associated with metabolic acidosis leading to cardiac
dysfunction and cardiogenic shock. Severe pulmonary edema
Tachypnea ↑ work of breathing
Physical findings Heart rate: 90-160bpm(upto 6 days of age)
SVT VT etc.
Precordial activity Heart sounds (S2,gallop rhythm, clicks) Murmurs (innocent, pathological) Peripheral arterial pulses Cyanosis
Investigations ECG
Chest X ray
Blood gas
Pulse oxymetry ECHO
What we do for screening in LH?
Pulse oxymetry (if abnormal)4 limb BP Blood gas Chest X ray ECG
ECHO (as required)
Pulse oxymetry Cutoff SpO2 <95%: sensitivity of 75% and
specificity of ≥90%
Do not detect Non cyanotic heart disease Left sided obstructive lesions with PDA
GA ≥35 weeks
Timing of screening: <24 hrs Vs ≥24 hrs of life. False positive more in < 24 hr group.
Factors affecting the test :ambient light, probe detachment, poor perfusion, dyshemoglobinaemias, crying, moving.
Decreases the cost
Criteria for positive screenFulfilling one of the following three criterion:
SpO2 <90 percent
SpO2 <95 percent in both upper and lower extremities on three measurements, each separated by one hour
SpO2 difference >3 % between the upper and lower extremities
Patient Reassessment CriteriaIf the saturation is < 95% in the right hand or
foot or >3% difference in right hand or foot repeat the screening after 1 hour.( first attempt)
If the saturation is < 95% in the right hand or foot or >3%difference in right hand or foot after the first attempt repeat the screening again after another 1 hour.(second attempt)
If the saturation remains <95% in the right hand or foot or >3%difference in right hand or foot after the second attempt the baby is considered to have a positive screen.
Newborn screening is directed for following lesions
Hypoplastic left heart syndrome Pulmonary atresia TOF TAPVR TGA Tricuspid atresia Truncus arteriosus
Management General supportive care
Antibiotics
Prostaglandin E1(specific cases)
Cardiac catheterization
Surgical intervention
Thank you
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