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NEONATAL HYPERTENSION

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Title: NEONATAL HYPERTENSION


1
NEONATAL HYPERTENSION
  • MARIFI DE JESUS U. CABALUNA, MD
  • PL-2
  • NOVEMBER 28, 2006

2
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 of
  • BP in both Term and Preterm infants?

3
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 history
  • and PE that points to neonatal
  • hypertension?

4
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?

5
DEFINITION
  • Systolic and/or diastolic BP gt/ 95
  • (gt 2 SD above the mean)
  • Stage 1 BP at 95 to lt 99
  • Stage 2 BP gt/ 99 5 mm Hg

6
BLOOD PRESSURE MEASUREMENT
  • Nwankwo 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.

7
BLOOD PRESSURE MEASUREMENT
  • STANDARDIZED 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

8
BLOOD PRESSURE MEASUREMENT
  • Wait 15 minutes or more of stillness
  • 3 successive readings at 2-minute
  • interval.

9
BLOOD PRESSURE MEASUREMENT
  • Intra-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.

10
BLOOD PRESSURE MEASUREMENT
  • INTRA-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

11
BLOOD PRESSURE MEASUREMENT
  • Leg pressures are higher than arm
  • pressures
  • Normal BP increases with gestational
  • age, post-conceptual age and
  • birthweight.

12
BLOOD PRESSURE MEASUREMENT
  • Zubrow 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

13
BLOOD PRESSURE MEASUREMENT
  • Zubrow 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

14
BLOOD PRESSURE MEASUREMENT
  • Zubrow 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

15
BLOOD PRESSURE MEASUREMENT
  • Postconceptual age/Postmenstrual
  • age (GA postnatal age) primary
  • determinant of BP in this population
  • RECOMMENDATION
  • BP consistently gt 95 confidence
  • limit by ZUBROW CURVES.

16
THE ZUBROW CURVE
17
INCIDENCE
  • General NICU population
  • .08 (26/3,179)
  • NICU admissions
  • 2 ( 20/988)
  • 0.7 to 3 in three studies

18
INCIDENCE
  • More common in patients with certain
  • diagnoses
  • BPD 6
  • PDA 3
  • IV hemorrhage 3
  • Umbilical catheterization 9

19
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

20
CAUSES OF NEONATAL HYPERTENSION
  • THROMBOEMBOLISM
  • 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.

21
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 fewer
  • ischemic complications and possibly decreased
    the
  • frequency of aortic thrombosis
  • Hypertension appears with equal frequency

22
CAUSES OF NEONATAL HYPERTENSION
  • RENAL 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

23
CAUSES OF NEONATAL HYPERTENSION
  • RENAL VEIN THROMBOSIS
  • Hypertension
  • gross hematuria
  • abdominal/flank mass
  • thrombocytopenia

24
CAUSES OF NEONATAL HYPERTENSION
  • CONGENITAL RENAL DISEASE
  • Polycystic kidney disease
  • autosomal dominant and recessive
  • enlarged kidney and hypertension
  • multicystic-dysplastic kidney disease
  • non-functional
  • ureteropelvic junction obstruction
  • Activation of Renin-angiotensin system

25
CAUSES OF NEONATAL HYPERTENSION
  • ACQUIRED RENAL DISEASE
  • ATN/Interstitial nephritis/cortical
  • necrosis
  • due to volume overload/hyperreninemia
  • HUS
  • Obstruction by a tumor

26
CAUSES OF NEONATAL HYPERTENSION
  • BRONCHOPULMONARY DYSPLASIA
  • 13- 43 of infants develop systemic
  • hypertension
  • cause unclear chronic hypoxia
  • severity (greater need for diuretics) of BPD
  • related to likelihood of developing
  • increased BP.
  • sickest infant require the closest monitoring

27
CAUSES OF NEONATAL HYPERTENSION
  • COARCTATION OF THE AORTA
  • early repair improves the long term
  • outcome
  • hypertension may persist even after
  • surgical repair

28
CAUSES OF NEONATAL HYPERTENSION
  • ENDOCRINE
  • seizures and increased intracranial
  • pressure are common causes of
  • episodic hypertension
  • CAH
  • HYPERALDOSTERONISM
  • HYPERTHYROIDISM

29
CAUSES OF NEONATAL HYPERTENSION
  • IATROGENIC
  • NICU meds
  • Dexamethasone
  • Theophylline
  • Caffeine
  • Pancuronium
  • Phenylephrine
  • Prolonged TPN
  • lead to salt and water overload/hypercalcemia
  • Under treatment of pain

30
CAUSES OF NEONATAL HYPERTENSION
  • MATERNAL CAUSES
  • Cocaine use
  • harm the developing kidneys
  • Heroine use
  • with neonatal withdrawal

31
CAUSES OF NEONATAL HYPERTENSION
  • NEOPLASMS
  • from compression of renal vessels and
    ureters
  • production of vasoactive substances
  • Neuroblastoma
  • Wilms tumor
  • Mesoblastic nephroma

32
CAUSES OF NEONATAL HYPERTENSION
  • MISCELLANEOUS CAUSES
  • closure of abdominal wall defect
  • adrenal hemorrhage
  • hypercalcemia
  • ECMO
  • birth asphyxia

33
EVALUATION
  • Life-threatening presentation
  • CHF
  • Cardiogenic shock
  • Seizures
  • Presentation of less ill infants
  • feeding difficulties
  • unexplained tachypnea
  • lethargy, apnea, irritability
  • mottling of the skin

34
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

35
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

36
EVALUATION
  • RED FLAGS IN THE PHYSICAL
  • EXAMINATION
  • Abdominal distention obstructive
  • uropathy, PKD, tumors
  • Peripheral thrombi UAC related HTN
  • Tachycardia/flushing/LBW
  • hyperthyroidism
  • Ambiguous genitalia - CAH

37
LABORATORY EXAMINATIONS
  • Urinalysis
  • CBC
  • Electrolytes, BUN, Crea, Ca
  • Urine culture if UTI is suspected
  • Plasma renin level significantly
  • elevated level indicates renovascular
  • disease

38
LABORATORY EXAMINATIONS
  • Additional tests
  • Thyroid studies
  • VMA/Homovanillic acid
  • Aldosterone
  • Cortisol

39
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

40
IMAGING STUDIES
  • Radionuclide imaging - Abnormal kidney displays
  • 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

41
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.

42
MANAGEMENT
  • RECOMMENDATION
  • Asymptomatic /Mild Hypertension
  • (Systolic 95th to lt 99th )
  • observation
  • resolves in time
  • Moderate to Severe
  • (Systolic gt/ 99th )
  • antihypertensive therapy

43
MANAGEMENT
  • Address correctible causes of
  • hypertension
  • treat pain
  • correct volume overload
  • wean inotropic infusion
  • Choose a suitable agent
  • depends on specific clinical situation

44
TREATMENT
  • ACUTELY ILL INFANTS
  • continuous IV infusion
  • intermittently administered agents cause
  • wide fluctuation in BP
  • PT are at increased risk for cerebral
  • ischemia and hemorrhage from rapidly
  • falling BPs.
  • allows titration for desired effect

45
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

46
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 still
  • elevated, add Sodium nitroprusside
  • then stop Nicardipine.

47
TREATMENT
  • NITROPRUSSIDE
  • potent vasodilator
  • rapid onset of action short duration of
  • effect
  • complications hypotension and
  • thiocyanate toxicity.

48
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.

49
TREATMENT (NeoReviews)
  • LESS SEVERE HYPERTENSION NOT READY FOR ORAL
  • Intermittent IV agents
  • Hydralazine
  • Labetalol
  • sometimes doses at lower end of
  • recommended range cause significant
  • hypotension

50
TREATMENT
  • HYDRALAZINE
  • peripheral vasodilator
  • relaxes vascular smooth muscle

51
TREATMENT (NeoReviews)
  • INFANT READY TO BE WEANED FROM IV / READY FOR
    ORAL
  • ORAL ANTIHYPERTENSIVE AGENTS
  • Captopril
  • Diuretic - can be added if captopril is
    ineffective
  • B Blocker should be avoided (BPD)

52
TREATMENT
  • CAPTOPRIL
  • Drug of choice
  • ACE inhibitor
  • .017 mg/kg/dose PO BID TID
  • Extremely low doses (0.01
  • mg/kg/dose or 0.03 mg/kg/day)
  • may be effective in newborns

53
TREATMENT
  • CAPTOPRIL
  • more potent in newborns
  • than older children because of
  • higher renal vascular resistance
  • longer duration of action

54
TREATMENT
  • BETA BLOCKER
  • effective in newborns
  • side effects uncommon
  • avoided in infants with BPD
  • because of bronchoconstriction

55
TREATMENT
  • DIURETICS
  • reduce extracellular and plasma
  • volume
  • use in newborns limited to mild
  • hypertension resulting from fluid
  • overload or as an adjunctive
  • medication.

56
TREATMENT (UPTODATE)
  • IV Enalapril
  • IV administered ACE inhibitor
  • effective in renovascular hypertension
  • has been used successfully in
  • newborns
  • lowest dose should be tried first

57
TREATMENT (NeoReviews)
  • IV Enalapril
  • avoided because of its unpredictable
  • antihypertensive efficacy and
  • potential to cause oligoanuria via
  • blockade of the renin-angiotensin
  • axis.

58
TREATMENT
  • Surgical correction
  • CoA
  • UPJ obstruction
  • Medical management surgery
  • Renal artery stenosis
  • Nephrectomy
  • Polycystic kidney disease
  • Chemotherapy surgery
  • Wilms tumor and Neuroblastoma

59
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

60
REFERENCES
  • Ettinger, Leigh et al Neoreviews Vol 3
  • No.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 3
  • No. 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

61
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