Patent Ductus Arteriosus as a Natural Cause of Pulmonary Hemorrhage in Infants

Pulmonary hemorrhage in neonatal respiratory distress syndrome: Radiographic evolution, course, complications and long-term clinical outcomes

BACKGROUND

Pulmonary hemorrhage (PH) is occasionally seen in premature infants after surfactant treatment for respiratory distress syndrome (RDS). These infants receive frequent chest radiographs (CXR) during and after hospitalization enabling long-term radiographic-clinical correlation.

OBJECTIVE

To chart the natural evolution of CXR findings of PH in RDS and correlate radiographic patterns to supplemental oxygen requirement.

MATERIALS AND METHODS

Retrospective review of clinical notes for gestational age (GA), birth weight (BW), intraventricular hemorrhage (IVH) and oxygen requirement were performed. CXRs were reviewed at 4 time-points; during PH, 28 days postnatal age, 36 weeks and at farthest available clinical follow-up.

RESULTS

18 infants born (2003-2016), GA (24-30 weeks); BW (482-1590 grams) were included. Mean onset of PH was 1.94 (0-5) days. 9/18 (50%) had IVH. 3 died during PH; all had IVH. During PH, CXR showed whiteout 9/18 (50%); patchy opacities 5/18 (27%); diffuse haziness 1/18 (6%) and no change 3/18 (17%). At 28 days postnatal age, CXR showed fine-interstitial (FI) markings 14/15 (93%) and whiteout 1/15 (7%). At 36 weeks,12/14 (85%) had FI and 2/14 (15%) developed cystic-interstitial changes. At farthest follow-up, FI 3/13 (23%); coarse-interstitial 4/13 (30%); peri-bronchial cuffing 5/13 (38%); normal 1/13 (9%) and the majority had hyperinflation 9/13 (69%). At discharge, 9/14 (64%) required home-oxygen and 5/14 (36%) were on room-air. At farthest follow-up, 6/14 (42%) required home-oxygen and 8/14 (58%) were on room-air.

CONCLUSION

Premature infants that survive PH may later develop chronic lung disease of prematurity with an evolving interstitial pattern on CXR that clears overtime as they outgrow the need for supplemental oxygen.

A prospective study of maternal preference for indomethacin prophylaxis versus symptomatic treatment of a patent ductus arteriosus in preterm infants

Background

The management of a patent ductus arteriosus in preterm infants continues to be debated among neonatologists due to the absence of concrete evidence that precisely weighs the long term outcomes of active, early intervention against a conservative approach. In the majority of institutions, parents are encouraged to play an active role in the complex, decision –making processes with regard to the care of their infants. The objective of this study is to elicit maternal preferences for indomethacin prophylaxis versus treatment of a patent ductus arteriosus (PDA) in extremely low birth weight (ELBW) infants, utilizing a decision aid instrument (DAI).

Methods

Healthy and high risk pregnant women at 23–28 weeks gestation, and mothers of admitted ELBW infants were enrolled. A computer based, validated DAI was utilized during interviews. The DAI first provides information about prematurity and concurrent morbidities with comprehensive facts of the pros and cons about prophylactic versus treatment options. It subsequently coaches participants how to select values and preferences based on their decisions. A 17-item questionnaire assessed and valued each short and long term morbidity of extreme prematurity and preferred choice for PDA management.

Results

Two hundred ninety nine subjects were enrolled; 75% were healthy women at 23–28 weeks gestation, 19% were high risk and 6% recently delivered an ELBW infant. Eighty-two percent preferred a prophylactic indomethacin strategy versus symptomatic treatment for the management of PDA. Across a spectrum of potential morbidities, the occurrence of severe intraventricular hemorrhage was viewed by mothers as the most un-wanted outcome irrespective of the two proposed options.

Conclusions

In contrast to neonatal practitioners, mothers who used this particular DAI strongly endorsed prophylactic indomethacin versus a treatment intervention for the management of PDA in preterm infants.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0353-4) contains supplementary material, which is available to authorized users.

A decision aid for considering indomethacin prophylaxis vs. symptomatic treatment of PDA for extreme low birth weight infants

BACKGROUND

Decision Aids (DA) are well established in various fields of medicine. It can improve the quality of decision-making and reduce decisional conflict. In neonatal care, and due to scientific equipoise, neonatologists caring for extreme low birth weight (ELBW) infants are in need to elicit parents' preferences with regard to the use of indomethacin therapy in ELBW infants. We aimed to develop a DA that elicits parents' preferences with regard to indomethacin therapy in ELBW infants.

METHODS

We developed a DA for the use of the indomethacin therapy in ELBW infants according to the Ottawa Decision Support Framework. The development process involved parents, neonatologists, DA developers and decision making experts. A pilot testing with healthy volunteers was conducted through an evaluation questionnaire, a knowledge scale, and a validated decisional conflict scale.

RESULTS

The DA is a computer-based interactive tool. In the first part, the DA provides information about patent ductus arteriosus (PDA) as a disease, the different treatment options, and the benefits and downsides of using indomethacin therapy in preterm infants. In the second part, it coaches the parent in the decision making process through clarifying values and preferences. Volunteers rated 10 out of 13 items of the DA positively and showed significant improvement on both the knowledge scale (p = 0.008) and the decisional conflict scale (p = 0.008).

CONCLUSION

We have developed a computer based DA to assess parental preferences with regard to indomethacin therapy in preterm infants. Future research will involve measurement of parental preferences to guide and augment the clinical decisions in current neonatal practice.

Management of patent ductus arteriosus in term or near-term neonates with respiratory distress

BACKGROUND

Respiratory distress and patent ductus arteriosus (PDA) in neonates are mutually perpetuating. Contrary to the situation in premature infants, the recognition, clinical relevance and optimal management of PDA in full-term neonates are unclear. The present study aimed to identify PDA as a possible cause of respiratory distress in term and near-term neonates, and to examine the clinical responsiveness of PDA to different treatment modalities in mature-gestational-age neonates.

METHODS

Patients with gestational ages of over 34 weeks were included in this retrospective chart review; they had PDA as the sole recognizable cause of respiratory distress and were free of all other diseases. Clinical responsiveness to different regimens, including conservative treatment, drug therapy with preload reduction and inotropic agent with or without the addition of indomethacin, and surgical intervention were analyzed.

RESULTS

Forty-four neonates qualified for this study. Six received no treatment and their cardiorespiratory symptoms resolved within 1 week (regimen A). Symptoms in 11 neonates were relieved after use of diuretic and inotropic agents (regimen B). Twelve neonates became asymptomatic without further intervention after indomethacin treatment in addition to preload reduction and inotropes (regimen C). A total of 15 of the 44 infants underwent PDA ligation (regimen D) due to persistent heart failure following regimens B or C, but had speedy resolution of respiratory symptoms following surgery. There were significant differences in birth body weight and hemodynamic variation based on left atrium to aortic root dimensional ratio between the treatment (regimens B, C and D) and non-treatment (regimen A) groups (p < 0.05).

CONCLUSION

PDA plays an important role in prolonging respiratory distress in term or near-term neonates. Although most infants respond to noninvasive medical treatment, surgical ligation during the neonatal period is warranted in certain mature infants. Surgical treatment should be considered in patients with smaller birth body weights and those with increased left atrium to aortic root dimensional ratios.

The frequency and significance of alveolar haemosiderin-laden macrophages in sudden infant death

Alveolar haemosiderin-laden macrophages (HLMs) in histological sections of the lung represent evidence of previous pulmonary haemorrhage and in infants may be associated with features of non-accidental injury (NAI). The aim of this study is to establish the frequency of alveolar HLMs detected at post-mortem in a large series of sudden unexpected infant deaths, and to determine their clinical significance with particular regard to a possible association with NAI. A search was performed of a database of 1516 anonymised paediatric autopsies to identify all infants (<1 year of age) that died suddenly and unexpectedly in whom HLMs were demonstrated on routine histological examination of lung sections using special iron (Perls') stains. Clinical details and other post-mortem findings were then reviewed. During the study period (1996-2005 inclusive), there were 601 sudden unexpected infant deaths. Of the 536 autopsies in whom histological data regarding HLMs were recorded and slides were available for review, 29 (5%) demonstrated alveolar HLMs in lung sections. In 9 (31%) infants there were additional features of NAI; in 11 (38%) infants, there were features in the clinical history and/or on pathological examination of natural disease sufficient to potentially explain the presence of HLMs, and 9 (31%) represented otherwise unexplained infant deaths with no significant clinical history or other abnormalities. HLMs were present in 9 of the 27 (33%) total infant deaths with other features indicative of NAI, compared to only 9 of the 242 (4%) unexplained infant deaths without any other features of NAI or other contributory pathology (difference 29.6%, 95% CI 14.6-48.6%, p<0.0001; positive likelihood ratio 9.0, 95% CI 3.9-19.8). This association remained even if cases with rib fractures were excluded. Alveolar HLMs may be identified in a significant minority of sudden infant deaths following routine histological examination of the lungs with special stains for iron pigment. In most, there will be features in the clinical history or findings at post-mortem to indicate underlying natural disease which may account for their presence. However, in the absence of such features, alveolar HLMs, whilst not diagnostic, are associated with a significantly increased risk for the detection of other features of NAI; the presence of otherwise unexplained alveolar HLMs at autopsy should therefore prompt a careful exclusion of inflicted injury.

The significance of hemosiderin deposition in the lungs and organs of the mononucleated macrophage resorption system in infants and children

Hemosiderin deposition is not often recognized on routine examination with hematoxylin and eosin staining; however, iron stains may be helpful in the evaluation of hemosiderin deposition in infant autopsies. This report describes the data obtained from autopsy of 86 infants and children whose deaths were investigated at the Forensic Medicine Council Bursa Morgue Department from January 2000 to January 2003. A histochemical technique was used to identify hemosiderin in lung, liver and spleen specimens, which was correlated with other descriptive variables such as the reported cause of death, postmortem interval, trauma history, gender, and age. There was a weakly positive but significant correlation between lung and liver hemosiderin scores (Spearman's rank correlation coefficient, rho=0.348, p=0.001); i.e., given an increase in lung hemosiderin scores, an increase in liver hemosiderin scores was also observed. Similarly, a marked positive correlation between spleen and liver hemosiderin scores (Spearman's rank correlation coefficient, rho=0.335, p=0.002) was observed. The probability of spleen hemosiderin-positive cases belonging to the age group under 6 months was found to be 4.3 times greater than those who were hemosiderin-negative (95% confidence interval, 1.6-11.8). After the major differential diagnoses were ruled out, this study demonstrated, that depending on the statistically assessed morphometric grounds, the presence of hemosiderin deposits in the liver and spleen were significantly higher in the age group under 6 months.

A prediction score model for risk factors of mortality in neonate with pulmonary hemorrhage: the experience of single neonatal intensive care unit in Southwest China

AIM

To establish a prediction score model for mortality of neonates with pulmonary hemorrhage (PH).

METHODS

Mortality risk factors of PH were analyzed by logistic regression analysis in 244 neonates retrospectively. A prediction score model was developed according to regression coefficients of risk factors. The receiver operating characteristic curve (ROC) was also constructed and the cutoff was determined.

RESULTS

The overall mortality rate of PH was 74.59% (182/244). More patients from multiple pregnancies were found in the death group than in the survivor group (20.1% vs. 3.2%, P = 0.023). The survivor group infants had higher birth weight in average than death group infants (2,787 g vs. 2,339 g, P = 0.000). Significant differences were found between survivor and death groups in the rates of intraventricular hemorrhage (IVH) (25.8% vs. 53.8%, P = 0.000), heart failure (22.6% vs. 48.9%, P = 0.000) and sepsis (3.2% vs. 16.5%, P = 0.008). Birth weight, IVH, heart failure and sepsis were identified as independent mortality risk factors by logistic regression analysis. A score model predicting death was developed according to the regression coefficients, with a sensitivity of 0.846, a specificity of 0.661, a positive predictive value of 0.88 and a negative predictive value of 0.594 at a cutoff of 9 points. The low risk group, with a score of 9 or less, had a lower mortality rate as compared with the high risk group (40.6% vs. 88%, P = 0.000).

CONCLUSIONS

Low birth weight, IVH, heart failure and sepsis were the risk factors for mortality of PH. Those infants with a predictive score of more than 9 were at high risk for death.