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8/4/2019 CabalunaDR Ppt 2006
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NEONATAL
HYPERTENSIONMARIFI DE JESUS U. CABALUNA, MD
PL-2
NOVEMBER 28, 2006
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QUESTIONS TO BE
ANSWERED What is the proper way of obtaining
BP in the neonate?
Does the device used in getting the
BP matters?
What is the primary determinant ofBP in both Term and Preterm infants?
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QUESTIONS TO BE
ANSWERED What are the common causes of
Hypertension among the neonates?
Does catheter tip placement play a
role in the incidence of Hypertension
among the neonates?
What are the RED FLAGS in historyand PE that points to neonatal
hypertension?
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QUESTIONS TO BE
ANSWERED What initial laboratory studies are
important?
Who should receive treatment ?
How do we choose a suitable agent?
Are there any medications to avoid?
Long term outcome and prognosis
depend on which factor?
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DEFINITION
Systolic and/or diastolic BP >/= 95%
(> 2 SD above the mean)
Stage 1 : BP at 95 to < 99 %
Stage 2 : BP >/= 99% + 5 mm Hg
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BLOOD PRESSURE
MEASUREMENTNwankwo et al
LBW and PT infants
BP is significantly lower in the prone
than supine position
First reading is significantly higher than
the third reading.
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BLOOD PRESSURE
MEASUREMENTSTANDARDIZED PROTOCOL
Check blood pressure 1.5 hours after
the last feeding or intervention
Apply appropriately sized cuff 2/3 the length of the limb segment
75% of the limb circumference
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BLOOD PRESSURE
MEASUREMENT
Wait 15 minutes or more of stillness
3 successive readings at 2-minute
interval.
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BLOOD PRESSURE
MEASUREMENTIntra-arterial catheters
most accurate technique
placed in aorta or radial artery continuous readings
Oscillometric devices
non-invasive ; continuous measure systolic and mean and calculate
diastolic pressure.
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BLOOD PRESSURE
MEASUREMENTINTRA-ARTERIAL CATHETERS VS.
OSCILLOMETRIC DEVICES
Low et al (study on 31 newborns) Average oscillometric pressures significantly
lower than intra-arterial pressures.
Systolic lower by 1 mm HG Mean pressure lower by 5.3 mm Hg
Diastolic pressure lower by 4.6 mm HG
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BLOOD PRESSURE
MEASUREMENT Leg pressures are higher than arm
pressures
Normal BP increases with gestational
age, post-conceptual age andbirthweight.
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BLOOD PRESSURE
MEASUREMENTZubrow et al (695 PT infant)
D1 Systolic and Diastolic correlate
strongly with BW and GA
First 5 days after birth
Systolic increase by 2.2-2.7 mm Hg/day
Diastolic increase by 1.6-2 mm Hg/
day regardless of BW and GA
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BLOOD PRESSURE
MEASUREMENTZubrow et al (695 PT infant)
After 5th Day more gradual
increments
Systolic 0.24-0.27 mm Hg/day
Diastolic 0 0.15 mm Hg/day
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BLOOD PRESSURE
MEASUREMENTZubrow et al (695 PT infant )
generated standard curves for mean
BP + upper and lower 95%confidence limits
regression lines developed based on
Birthweight Gestational age
Postconceptual age
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BLOOD PRESSURE
MEASUREMENT Postconceptual age/Postmenstrual
age (GA + postnatal age)primary
determinant of BP in this population
RECOMMENDATION BP consistently > 95% confidence
limit by ZUBROW CURVES.
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THE ZUBROW CURVE
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INCIDENCE
General NICU population
.08% (26/3,179)
NICU admissions
2% ( 20/988)
0.7 to 3 % in three studies
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INCIDENCE
More common in patients with certain
diagnoses :
BPD 6 %
PDA 3 %
IV hemorrhage 3 % Umbilical catheterization 9 %
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CAUSES OF NEONATAL
HYPERTENSION RENOVASCULAR
most common
thromboembolism umbilical artery catheters as theoretical sources of
thomboembolic events
studies established an association between local
thrombi and development of hypertension
renal artery stenosis
renal venous thrombosis
compression of renal artery
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CAUSES OF NEONATAL
HYPERTENSIONTHROMBOEMBOLISM
COCHRANE STUDY
analysis of 11 randomized clinical trials
one study using alternate assignments
To compare the incidence of
morbidity and mortality for HIGH Vs.
LOW catheter tip placement.
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CAUSES OF NEONATAL
HYPERTENSION HIGH in the descending aorta
above the diaphragm (T6 and T9) LOW above the bifurcation but below the renal
arteries (L3 and L5)
CONCLUSION
High catheter positions caused fewerischemic complications and possibly decreased thefrequency of aortic thrombosis
Hypertension appears with equal frequency
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CAUSES OF NEONATAL
HYPERTENSIONRENAL ARTERY STENOSIS
caused by fibromuscular dysplasia
if present there also may be mid-
aortic coarctation and cerebral
vascular stenosis may be due to congenital rubella
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CAUSES OF NEONATAL
HYPERTENSIONRENAL VEIN THROMBOSIS
Hypertension
gross hematuria
abdominal/flank mass
thrombocytopenia
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CAUSES OF NEONATAL
HYPERTENSIONCONGENITAL RENAL DISEASE
Polycystic kidney disease
autosomal dominant and recessive enlarged kidney and hypertension
multicystic-dysplastic kidney disease
non-functional ureteropelvic junction obstructionActivation of Renin-angiotensin system
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CAUSES OF NEONATAL
HYPERTENSIONACQUIRED RENAL DISEASE
ATN/Interstitial nephritis/cortical
necrosis
due to volume overload/hyperreninemia
HUS
Obstruction by a tumor
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CAUSES OF NEONATAL
HYPERTENSIONBRONCHOPULMONARY DYSPLASIA
13- 43% of infants develop systemic
hypertension cause unclear : chronic hypoxia
severity (greater need for diuretics) of BPD
related to likelihood of developingincreased BP.
sickest infant require the closest monitoring
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CAUSES OF NEONATAL
HYPERTENSIONCOARCTATION OF THE AORTA
early repair improves the long term
outcome
hypertension may persist even after
surgical repair
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CAUSES OF NEONATAL
HYPERTENSIONENDOCRINE
seizures and increased intracranial
pressure are common causes of
episodic hypertension
CAH
HYPERALDOSTERONISM
HYPERTHYROIDISM
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CAUSES OF NEONATAL
HYPERTENSIONIATROGENIC NICU meds Dexamethasone
Theophylline Caffeine Pancuronium Phenylephrine
Prolonged TPN lead to salt and water overload/hypercalcemia
Under treatment of pain
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CAUSES OF NEONATAL
HYPERTENSIONMATERNAL CAUSES
Cocaine use
harm the developing kidneys
Heroine use
with neonatal withdrawal
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CAUSES OF NEONATAL
HYPERTENSIONNEOPLASMS
from compression of renal vessels and
ureters production of vasoactive substances
Neuroblastoma
Wilms tumor Mesoblastic nephroma
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CAUSES OF NEONATAL
HYPERTENSIONMISCELLANEOUS CAUSES
closure of abdominal wall defect
adrenal hemorrhage
hypercalcemia
ECMO
birth asphyxia
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EVALUATION
Life-threatening presentation
CHF
Cardiogenic shock
Seizures
Presentation of less ill infants
feeding difficulties
unexplained tachypnea
lethargy, apnea, irritability
mottling of the skin
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EVALUATION
RED FLAGS IN THE HISTORY
prenatal exposures to heroin and
cocaine predisposing conditions BPD, CNS
disorders, PDA, hypervolemia (post
BT) Medications/ Umbilical artery
catheterizations
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EVALUATION
RED FLAGS IN THE PHYSICAL
EXAMINATION
BP in lower extremities/non-palpable
femoral pulses CoA
dysmorphic features CAH/Turner Sy
Flank mass UPJ obstruction
Epigastric bruit renal artery stenosis
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EVALUATION
RED FLAGS IN THE PHYSICAL
EXAMINATION
Abdominal distention obstructiveuropathy, PKD, tumors
Peripheral thrombi UAC related HTN
Tachycardia/flushing/LBWhyperthyroidism
Ambiguous genitalia - CAH
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LABORATORY
EXAMINATIONS Urinalysis
CBC
Electrolytes, BUN, Crea, Ca
Urine culture if UTI is suspected
Plasma renin level significantly
elevated level indicates renovascular
disease
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LABORATORY
EXAMINATIONSAdditional tests
Thyroid studies
VMA/Homovanillic acid
Aldosterone
Cortisol
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IMAGING STUDIES
CXRay/2D echo CHF
US of genitourinary tract
should be performed in all hypertensive infants to rule out UPJ obstruction, renal vein
thrombosis
Doppler flow studies
Abdominal/pelvic US
VCUG
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IMAGING STUDIES
Radionuclide imaging - Abnormal kidneydisplays:
decreased effective renal plasma flow decreased urine flow rate
increased isotope concentration
MRA gold standard for diagnosis of
reno vascular hypertension
must be 3 kg
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MANAGEMENT
optimal management uncertain
threshold for starting antihypertensive
has not been well defined
idiosyncratic responses to certain
drugs due to developmental
immaturity of liver and kidney
function.
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MANAGEMENT
RECOMMENDATION
Asymptomatic /Mild Hypertension
(Systolic 95th to < 99th %) observation
resolves in time
Moderate to Severe(Systolic >/= 99th %) antihypertensive therapy
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MANAGEMENT
Address correctible causes of
hypertension
treat pain
correct volume overload
wean inotropic infusion
Choose a suitable agent depends on specific clinical situation
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TREATMENT
ACUTELY ILL INFANTS
continuous IV infusion
intermittently administered agents causewide fluctuation in BP
PT are at increased risk for cerebral
ischemia and hemorrhage from rapidly
falling BPs.
allows titration for desired effect
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TREATMENT
ACUTELY ILL INFANTS
continuous IV infusion
Nicardipine - DOC Nitroprusside
Labetalol cathecholamine and CNS
mediated hypertension
- avoid in BPD
monitor BP Q 10-15 minutes
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TREATMENT
NICARDIPINE calcium channel blocker peripheral vasodilator short half life : 10-15 minutes IV infusion 0.5 mcg/kg/min if normal BP
not achieved in 15 minutes increase
infusion to max of 3 mcg/kg/min. If stillelevated, add Sodium nitroprussidethen stop Nicardipine.
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TREATMENT
NITROPRUSSIDE
potent vasodilator
rapid onset of action short duration of
effect
complications : hypotension and
thiocyanate toxicity.
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TREATMENT
LABETALOL
combined alpha-1 and beta-blocker
rapid onset of action
duration of action : 2-3 hours
do not cause tachycardia, cerebral
vasodilatation or changes in
intracranial pressure.
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TREATMENT(NeoReviews)
LESS SEVERE HYPERTENSION NOTREADY FOR ORAL
Intermittent IV agents Hydralazine
Labetalol
sometimes doses at lower end ofrecommended range cause significant
hypotension
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TREATMENT
HYDRALAZINE
peripheral vasodilator
relaxes vascular smooth muscle
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TREATMENT(NeoReviews)
INFANT READY TO BE WEANED FROMIV / READY FOR ORAL
ORAL ANTIHYPERTENSIVE AGENTS Captopril
Diuretic - can be added if captopril is
ineffective B Blocker should be avoided (BPD)
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TREATMENT
CAPTOPRILDrug of choice
ACE inhibitor .017 mg/kg/dose PO BIDTID Extremely low doses (0.01
mg/kg/dose or 0.03 mg/kg/day)may be effective in newborns
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TREATMENT
CAPTOPRIL
more potent in newbornsthan older children because of
higher renal vascular resistance
longer duration of action
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TREATMENT
BETA BLOCKER
effective in newborns
side effects uncommon
avoided in infants with BPD
because of bronchoconstriction
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TREATMENT
DIURETICS
reduce extracellular and plasma
volume
use in newborns limited to mild
hypertension resulting from fluid
overload or as an adjunctive
medication.
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TREATMENT(UPTODATE)
IV Enalapril
IV administered ACE inhibitor
effective in renovascular hypertension
has been used successfully in
newborns
lowest dose should be tried first
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TREATMENT(NeoReviews)
IV Enalapril
avoided because of its unpredictable
antihypertensive efficacy and
potential to cause oligoanuria via
blockade of the renin-angiotensin
axis.
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TREATMENT
Surgical correction CoA
UPJ obstruction
Medical management + surgery Renal artery stenosis
Nephrectomy
Polycystic kidney disease Chemotherapy + surgeryWilms tumor and Neuroblastoma
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PROGNOSIS
depends on the cause often resolves over time persistent polycystic kidney disease renal parenchymal disease renal vein thrombosis require
nephrectomy
recurrent restenosis of renal artery stenosis or CoA
after repair
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REFERENCES
Ettinger, Leigh et al : NeoreviewsVol 3No.8. 2002
Fanaroff, Jonathan, et al. Blood pressure disorders
in the Neonate : Hypotension and Hypertension.Seminars in Fetal and Neonatal Medicine Vol 11.No. 3, June 2006, 174-181.
Ettinger, Leigh et al : Neoreviews.Vol 3No. 8, 2002
Neonatal Hypertension : Uptodate.2006 Neonatal Hypertension : Emedicine. August
29, 2006 Sondheimer, Judith M. (editor) : Current
Pediatric Diagnosis and Treatment. 16th ed.McGraw-Hill Companies,2003
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THANK YOU
ANDGOOD MORNING
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