Pathophysiology, clinical manifestations, and diagnosis of patent ductus arteriosus in premature infants
- Joseph B Philips III, MD, FAAP
Joseph B Philips III, MD, FAAP
- Professor of Pediatrics
- University of Alabama at Birmingham
- Section Editors
- Joseph A Garcia-Prats, MD
Joseph A Garcia-Prats, MD
- Section Editor — Neonatology
- Professor of Pediatrics
- Baylor College of Medicine
- David R Fulton, MD
David R Fulton, MD
- Section Editor — Pediatric Cardiology
- Associate Professor of Pediatrics
- Harvard Medical School
The ductus arteriosus (DA) is an important vascular connection between the main pulmonary artery and the aorta (figure 1). During fetal life, the DA diverts blood from the pulmonary artery into the aorta, thereby bypassing the lungs. After birth, the DA undergoes active constriction and eventual obliteration. A patent ductus arteriosus (PDA) occurs when the ductus fails to completely close after delivery.
PDA occurs commonly in premature infants, especially in those with respiratory distress syndrome. In very low birth weight (VLBW) infants (birth weight below 1500 g) the incidence of PDA is about 30 percent .
The pathophysiology, clinical features, and diagnosis of PDA in premature infants are reviewed here. The management of PDA in premature infants as well as the diagnosis and treatment of PDA in older infants and children are discussed separately. (See "Management of patent ductus arteriosus in preterm infants" and "Clinical manifestations and diagnosis of patent ductus arteriosus in term infants, children, and adults".)
FETAL AND TRANSITIONAL DUCTAL CIRCULATION
In the fetus, constriction of the pulmonary arteries leads to high vascular resistance, whereas the fetal systemic vascular resistance is low as a large proportion of the systemic circulation (about 40 percent) flows into the placenta, which has a very low vascular resistance . As a result, the majority of the blood flow exiting from the right ventricle bypasses the pulmonary arteries in a right-to-left shunt across the ductus arteriosus (DA) into the descending aorta and on to the placenta (figure 2 and algorithm 1). In the fetus, because of the large right-to-left shunting of blood, the ductus is a large vessel with a diameter similar to that of the descending aorta (figure 1). (See "Physiologic transition from intrauterine to extrauterine life".)
With the onset of respiration after delivery, the lungs expand and the systemic oxygen saturation rises, resulting in pulmonary vasodilatation and a drop in pulmonary vascular resistance. At the same time, systemic resistance rises with placental removal. These factors lead to a sudden reversal of blood flow in the DA from right-to-left to left-to-right shunting. (See "Physiologic transition from intrauterine to extrauterine life".)
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- FETAL AND TRANSITIONAL DUCTAL CIRCULATION
- Patency of the ductus
- - Prostaglandin E2
- - Nitric oxide
- Ductal constriction
- Permanent closure
- - Term infants
- - Preterm infants
- - Reopening
- PHYSIOLOGIC EFFECTS AND CLINICAL IMPLICATIONS
- Pulmonary effects
- - Pulmonary edema
- - Pulmonary hemorrhage
- - Bronchopulmonary dysplasia
- Systemic and cerebral blood flow effects
- CLINICAL FEATURES
- Significant PDA
- SUMMARY AND RECOMMENDATIONS