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• Combined lower body blood + umbilical venous blood flow passes through IVC to
the right atrium
• Part of IVC blood with high O2 concentration
goes into LA via Foramen Ovale.
• Remaining IVC blood enters RV.
• Most of SVC blood goes to the RV traversing the
tricuspid valve and into the pulmonary trunk.
Because the pulmonary arterial circulation is
vasoconstricted, only about 10% of right
ventricular outflow enters the pulmonary
arteries. The rest 90% blood bypasses the lungs
and flows through the ductus arteriosus into the
descending aorta to perfuse the lower part of
the fetal body.
• The left atrium receives blood from :
- Pulmonary veins
- Right atrium through the foramen ovale
• This blood passes into left ventricle then into the
aorta supplying head,neck,brain and upper
extremities through carotid and subclavians,
then mixes with poorly oxygenated blood from
the ductus arteriosus and perfuses the rest of the
body through branches of descending aorta.
Overview of fetal circulatory
dynamics
• Parallel arrangement of two main arterial
systems and their respective ventricles.
• Mixing of venous return and preferential
streaming.
• High resistance and low flow of pulmonary
circulation.
• Low resistance and high flow of systemic
circulation.
• Presence of shunts.
Perinatal circulatory transition
At birth
- Foramen ovale :
Functional Closure: 3rd month of life.
Anatomical closure of septum primum & septum
secundum by 1 year of age.
- Ductus arteriosus :
Functional Closure: By 10–15 hr in a normal neonate.
Anatomic closure: May take several weeks.
In a full-term neonate, oxygen is the most important
factor controlling ductal closure.
When the PO2 in the blood passing through the ductus
reaches about 50 mm Hg , the ductal wall constricts.
3. Removal of the placenta from the circulation
Fetal myocardium
Contractility,Compliance Less Good
• PRIMARY PPHN
• SECONDARY PPHN
DIAGNOSIS
• Presents within 18 hours of birth
• Respiratory distress
• Marked cyanosis
• Differential cyanosis between regions
perfused by preductal and postductal
vasculature
• Prominent precordial impulse
• Loud,single or narrowly split S2
• Systolic murmur
• A gradient of 10% or more in oxygen
saturation between preductal and postductal
areas
• CXR appears normal or shows associated
parenchymal lung disease
• ECG shows RV strain or hypertrophy
• ECHO shows hemodynamic shunting,helps to
evaluate ventricular function,tricuspid
insufficiency and to exclude congenital heart
disease
• Color doppler shows presence of
intracardiac/ductal shunting
MANAGEMENT
• Case fatality rate of 30-60%
• Requires immediate intervention to reverse
hypoxemia,improve pulmonary and systemic
perfusion,preserve end organ function
• Supplemental oxygen
(postductal SaO2 is > 90% and < 98%)
• Intubation,mechanical ventilation
(persisting hypoxemia,hypercapnea,acidosis)
o In the absence of pulmonary disease -> mechanical
ventilation with rapid,low pressure and short
inspiratory time
o PPHN + parenchymal lung disease ->
High frequency oscillatory ventilation/High
frequency jet ventilation (MAS,air leak)
• Sildenafil
o PDE-5 inhibitor
o Inhibits metabolism of NO
o >> available NO
o Dose : 0.4mg/kg/dose IV over 3hrs
followed by a continuous infusion of
1.6mg/kg/24hrs
for upto 7days
• iNO
>>cGMP
pulmonary vasodilation
o Started at a dose of 20ppm.
o Delivered via the ventilator circuit.
o Most effective when administered after adequate
alveolar recruitment(by use of HFOV / surfactant).
o When the condition improves,dose is slowly
tapered by halving.
o Stopped when SaO2 is adequate on FiO2 of < 50%
and i NO dose of 1ppm.
o High doses lead to methemoglobinemia.
o Abruptly stopping iNO leads to rebound hypoxemia.
• ECMO
o Extra Corporeal Membrane Oxygenation
o Used when conventional therapy and iNO
treatment fails
o Criteria to start ECMO : oxygenation index of
>30 in 2 ABG’s taken 30 minutes apart
&
alveolar-arterial oxygen difference > 600
• Intravascular volume support
• Dobutamine and vasopressors
• Correct hypoglycemia,hypocalcemia
(to provide adequate substrates to the myocardium)
• Neutral/alkalotic pH reduces PVR
(by sodium bicarbonate boluses)
• Sedation and analgesia with fentanyl/morphine
(prevents release of catecolamines which activate
pulmonary adrenergic receptors)
• Muscle relaxants like pancuronium
• Correct polycythemia,hyperviscosity
(partial exchange transfusion with normal saline to
maintain HCT between 50-55%)
• Other therapies : Magnesium sulfate , adenosine ,
tolazoline , calcium channel blockers , inhaled
prostacyclin , inhaled ethyl nitrite
PROGNOSIS
• Neurodevelopmental sequelae in 15-20%
• Hyperventilation reduces cerebral perfusion,
leads to sensorineural hearing loss
• Prolonged ventilation leads to development of
chronic lung disease
• 20% risk of rehospitalization within 1 year of
discharge