1) The document discusses the approach to cyanosis in term neonates through case scenarios and discussions of common and uncommon presentations.
2) It covers the fetal circulation, changes at birth, pathologies that can interfere with transition including persistent pulmonary hypertension of the newborn (PPHN), and the diagnostic approach including tests to differentiate PPHN from congenital heart disease.
3) Three case scenarios are presented and discussed to demonstrate different causes of cyanosis including PPHN, total anomalous pulmonary venous connection, and methemoglobinemia. The importance of a thorough evaluation and involvement of specialists is emphasized.
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Cyanosis in term neonates – A problem oriented approach
1. Cyanosis in term neonates – A
problem oriented approach
Dr.Gopakumar.H
Assistant Professor
Dept of Neonatology
AIMS , Kochi
2. Aims
• To provide a brief approach to
cyanosis in term neonates
• Representative case scenarios and
discussion
Common presentation of common condition
Uncommon presentation of common condition
Uncommon presentation of uncommon condition
• Fetal circulation and basic
physiology
5. Changes with onset of
respiration
• Breathing initiates abrupt
fall in pulmonary vascular
resistance
• Gas exchange function
transferred from placenta
to lungs
• Concurrent increase in
blood flow to the lungs .
Pulmonary arterioles dilate
in response to increased
oxygen saturation
• Closure of 3
communicating channels -
ductus arteriosus , ductus
venosus and foramen ovale
03/14/12
6. Pathology of PPHN
• Any condition that
interferes with normal
perinatal transition
• Hypoxia and acidosis –
pulmonary
vasoconstriction
( impaired perinatal
transition as in birth
asphyxia , MAS etc )
• Pulmonary hypoplasia
• Premature closure of
ductus arteriosus as in
maternal NSAID
therapy
03/14/12
7. Diagnostic dilemma in hypoxemia
in a full term neonate
• Cyanotic congenital heart
disease
• Persistent pulmonary
hypertension
03/14/12
8. Identifying right to left
shunt
• Obtain ABG from right radial artery
( preductal ) and posterior tibial
artery ( postductal ) simultaneously
• A higher PaO2 in right radial artery
sample by 20 mm of Hg indicates
presence of right to left shunting
• An SpO2 difference may also
suggest right to left shunting
03/14/12
9. Hyperoxia test
• Place infant in 100% oxygen
concentration for 5 to 10 minutes
• Sample arterial blood
• Persistent hypoxia after 5 to 10
minutes of 100% oxygen exposure
suggest presence of right to left
shunting
• If PaO2 > 100 mm of Hg , CCHD more
or less ruled out
03/14/12
10. Hyperoxia – hyperventilation test
• Hypoxia and acidosis causes pulmonary
vasoconstriction
• Alkalosis and increased blood oxygen can decrease
pulmonary vascular resistance
• By increasing minute ventilation – PaCO2 falls and
pH rises . This markedly increase pH and may
result in dramatic increase in PaO2
• A dramatic increase along with extreme lability of
PaO2 is more suggestive of PPHN
• Differentiates PPHN from CCHD
• CCHD – fixed right to left shunting ( PaO2 between
40 to 50 mm Hg ) even with inhalation of 100%
oxygen and hyperventilation
03/14/12
11. Essential diagnosis of PPHN
• Risk factors ( Birth asphyxia / MAS /
Pneumonia etc )
• Chest Ray usually normal /
underlying lung condition
• ABG – Low PaO2 in the face of high
FiO2
• Echo – to rule out congenital
cyanotic heart disease and to
diagnose PPHN
03/14/12
13. Case scenario
• Term male baby with birth weight of
3.7kg
• Born to IDM mother by Elective LSCS at an
outside hospital
• ANP uneventful
• Baby cried immediately after birth
• Tachypneoic - 70/min - shifted to NICU .
• Managed in hood oxygen along with other
supportive measures
• On Day 2 Baby had increasing tachypnea
03/14/12
14. On examination
• Spo2 on 5ltrs O2
-90-92%, not much
difference b/n upper
and lower limb.
• Other systems – within
normal limits
• Chest x-ray –
Bronchopneumonia
• Echo done at referring
hospital – PPHN
• Referred for further
management
03/14/12
15. Admission in AIMS
• Baby tachypnic
• Spo2 on 5ltrs O2 85-88%, No
significant upper and lower
limb difference
• Blood pressure – WNL
• CVS - S2 appeared loud
• Systolic murmur at tricuspid
area
• ABG( preductal) - On 100%
Fio2
• pH – 7.23, PO2 –
45mmHg, PCO2 –
55mmHG, HCO3-15mmol
• Chest X-ray – suggestive
of Bronchopneumonia
03/14/12
17. Problems
• Tachypnea in a term neonate
since birth
• Differentiation between PPHN
and CHD
• Discordance between clinical
suspicion of sepsis / pneumonia
and lab investigation ( No risk
factors of sepsis )
• Low PaO2 in Hyperoxia –
hyperventilation test
Detailed cardiac evaluation
21. Case scenario
• A Term male baby ( birth weight of 3.5 kg )
• Mother with uncontrolled gestational
diabetes mellitus
• Elective LSCS at 38wks gestational age at
outside hospital
• Cried soon after birth
• Developed tachypnea soon after birth
• Initially managed with O2 hood
• At 4hrs after birth - Tachypnea
worsened.Had desaturation to around 85%
in hood oxygen and hence referred to AIMS
with suspected CCHD
03/14/12
22. On admission in
AIMS
• Baby had tachypnea . No chest retractions
or grunt
• Cyanotic with an Oxygen saturation about
75%
• Had tachycardia with low pulse volume
• Hyperoxia test –saturation improved to
82%
• Chest X-ray from outside – mild
cardiomegaly, Lung fields clear(adequate
lung volume )
• ABG - pH 7.2, PCO2 – 60mmHg, PO2 –
34mmHG, HCO3 – 14mmol
• PCV – 71 %
03/14/12
23. Possibilities
• Cyanotic heart disease
• Persistent pulmonary
hypertension
Uncontrolled GDM
Elective LSCS without
induction of labour
Polycythemia
Presumed Chronic hypoxia
03/14/12
24. Cardiac evaluation
• Emergency Echo– No
structural heart disease
• Mild PPHN – oxygenate well,
Treat the precipitating
cause –? Polycythemia,
03/14/12
25. Management
• Baby was ventilated
after 2hrs in view of
severe hypoxia and
features of respiratory
failure
• Hb – 24gm%, PCV –
71%
• Chest X-ray- lungs
fields normal , Mild
cardiomegaly
• Preductal- 88%,
Postductal- 82% on
Fio2- 100%
03/14/12
26. Management
Ventilatory
adjustements were
changed based on CXR
and ABG results .
Standard management
for PPHN was
instituted
partial exchange
Baby improved with
management
03/14/12
Chest –x-ray after 6hrs .
27. Highlights – Multiple risk factors for
PPHN
• Infant of poorly controlled
diabetic mother
• Born without labour pains –
delayed clearance of lung fluid
• Delayed administeration of
CPAP
• Polycythemia
03/14/12
28. Differentiating PPHN from CCHD
PPHN CCHD
History Risk factors( NSAID ) May have positive
family history
Delivery Fetal distress / birth Uneventful
asphyxia
Examination Respiratory and / or May have cardiac
neurological signs signs
Chest X ray F/0 resp path Often non specific
ECG Non specific May have clear
abnormality ( Usually
non specific )
Hyperoxia test Variable response . Often low fixed PaO2
Fluctuating oxygen
tension
Upper limb / lower Lower limb Sometimes
limb saturations saturation often discrepent
lower
Echo Rules out structural Diagnosis
heart disease
30. Case scenario
• Term AGA male baby
• Elective LSCS ( persistent breech) in
outside hospital,.
• Baby had mild tachypnea initially , which
settled with 2lts of free flow O2 for 2hrs.
• At 18hrs of birth , baby had bluish
discoloration of extremities and lips
• Shifted the baby to NICU in view obvious
cyanosis, tachypnea and SPO2 of 80%.
SPO2 did not improve with hood oxygen
• Systemic examination was within normal
limits exept for tachypnea and low SPO2
• Baby shifted to AIMS
03/14/12
31. Admission in AIMS
• Supportive measures
given
• Sepsis screen done –
Negative
• Chest X-ray done – Normal
• PH- 7.26, PO2 – 300
mmHg , PCO2 40 ,
Lactate – 8 mmol, HCO3 –
17mmol, BE- 15 mmol.-
suggestive of Acidosis
with lactate build up –
( peripheral perfusion
problem )
• Echo – reported normal
• Arterial blood was dark
brownish
03/14/12
32. Problems
• Cyanosis
• Normal PaO2
• Low SpO2
• Sepsis screen negative
• Peripheral perfusion problem
• Dark arterial blood
Discordance between clinical suspicion and investigations
Normal PaO2 and low SpO2
? Impairment in tissue release
03/14/12
33. Clinical progress
• Baby worsened over 1hr , Baby
irritablilty increased
• Spo2 dropped to 75% on 6ltrsd O2 ,
cyanosis worsened – electively
intubated
• Echo – no structural heart disease /
PPHN
• ABG – pH – 7.48, PCO2- 35 mm,
PO2-300 mmHG , But corresponding
overnight Spo2 persisted around
85-88%.Baby still looked cyanotic.
Dark colour of blood – with normal PaO2
?Hematologic problem
03/14/12 Methemoglobin levels sent
34. Methhemoglobin - revealed 21% total Hb%.
Hematology consultation done – supportive
measures , correction of metabolic
acidosis and Blood transfusion / ET advised
Improved with transfusion ( deferred
exchange transfusion )
Methylene blue not availabe
Baby gradually improved over the next 2
days and was off ventilator
To repeat Methemoglobin levels at a later
date
Methemoglobinemia – probably transient
03/14/12
35. Causes of cyanosis
• Relatively high levels of
deoxyhemoglobin – generally
more than 5 gm / dL
• When nonphysiologic hemoglobin
( eg – Methemoglobin is present
more than 1.5 gm / dL )
03/14/12
36. Causes of acquired methemoglobinemia
• Metabolic acidosis
• Exposure to certain drugs
• Nitrites
• Nitrate containing compounds
Definitive treatment – Methylene blue
03/14/12
37. Neonatal cyanosis
Category Details Comments
Respiratory Any respiratory disease
Cardiac Common mixing Especially if
TAPVC obstructed
Truncus arteriosus Cardiac failure
Right to left shunts
Pulmonary atresia ( IVS )
Pulmonary atresia ( VSD )
Tricuspid atresia , TGA
PPHN ( includes CNS
insult )
Hematologic Methemoglobinemia Grey / blackish blood .
Arterial oxygen
tension normal
03/14/12
38. Summary
• Respect respiratory distress in a term
Neonate
• Consider early CPAP to recruit lung volume
• Differentiate PPHN and CCHD .Role of early
pediatric cardiology evaluation
• Discordance between clinical suspicion
and labortary result – think of an
alternative diagnosis as well
• Involve experienced specialists at the
earliest to guide management decisions
03/14/12
39. Acknowledgement
• Dr.Rajiv . P.K
• Dr.Mathew Kripail
• Dr.Sudheer
• Dr.Sivji
• Dr.Sunil .B
• Dr.Ashwin Prabhu
• Dr.Prasanna
• Dr.Laxmikanth
• All specialists ( Pediatric cardiology and
Hematology ) and Nursing staff involved in
the mangement of sick babies
03/14/12