MANAGEMENT OF PATENT DUCTUS ARTERIOSUS IN VERY PRETERM NEWBORNS: CURRENT CONTROVERSIES AND RECOMMENDATIONS

Abstract

According to numerous studies, the persistence of patent ductus arteriosus (PDA) in very preterm infants is associated with increased morbidity and mortality. The prophylactic use of drugs that prevent or reduce the hemodynamic significance of PDA in preterm infants has several short-term benefits, including reduction in the incidence of symptomatic PDA, severe intraventricular hemorrhages (IVH) and the need for additional medical or surgical treatment. At the same time, this approach does not affect the long-term outcomes of such patients. Pre-symptomatic treatment with cyclooxygenase inhibitors before the time of appearance of symptoms caused by PDA generally does not affect mortality, but significantly reduces the incidence of symptomatic PDA and the need for pharmacological and surgical treatment. Pre-symptomatic treatment of PDA may be of value in extremely preterm infants born within 23-25 wk of gestation taking into account the high incidence of hemodynamically significant PDA (hsPDA) requiring further treatment in such newborns. Treatment of clinically obvious PDA may minimize the risk of exposing preterm infants to the treatment with undesirable side effects. At the same time, the disadvantages of late intervention are lower success rate and an increased risk of complications associated with hsPDA. Expectant management of PDA in preterm newborns is gaining increasing interest because in a substantial proportion of preterm infants, the PDA will close spontaneously and there is a lack of proven benefit of medical treatment. This approach is not associated with a higher risk of death, necrotizing enterocolitis (NEC), or IVH than any other treatment approaches. A conservative approach aimed to close PDA (fluid restriction, diuretics, etc.) can contribute to avoidance of medical and surgical intervention and their potential side effects only in some preterm infants with gestation > 26 wk, without affecting mortality and quality of survival. However, such a therapy is associated with a high risk of dehydration, development of hyponatremia, and an increase in serum creatinine, that is why it isn’t routinely recommend.