Fetal Cardiovascular

Ductus Arteriosus

•In the fetus, the ductus arteriosus connects the pulmonary artery and the aorta. Most of the blood that enters the pulmonary artery passes into the aorta and bypasses the non functioning lungs.

Foramen Ovale

•It is a flap in the septum between the right and left atrium of the fetal heart. •It allows oxygenated blood from the inferior vena cava to move from the right atrium to the left.

Classification of Congenital Heart Disease

1. Left to right shunting. 2. Obstructive or stenotic lesions. 3. Cyanotic lesions with decreased pulmonary blood flow. 4. Cyanotic lesions with increased pulmonary blood flow.

Congenital Heart Disease: Prenatal Factors

1. Maternal Rubella German Measles. 2. Maternal alcoholism, obesity, smoking. 3. Maternal age over 40. 4. Maternal infection. 5. Maternal diabetes type I.

Atrial Septal Defect Symptoms

1. May be asymptomatic. 2. Recurrent respiratory infections. 3. May develop CHF. 4. Murmur-may not be present in infants. 5. Atrial arrhythmia.

Ventricular Septal Defect Signs and Symptoms

1. Murmur. 2. CHF may occur. 3. Poor feeding and failure to thrive.

Circulatory Readjustments After Birth

E. Closure of the ductus venosus: This liver bypass conducts blood from umbilical vein to the inferior vena cava. When umbilical blood flow ceases immediately after birth, portal blood still bypasses the liver via the ductus venosus, until the ductus venosus contracts one to three hours after birth.

Ductus Arteriosus

•As the newborn takes the first breaths of air at birth, the rise in oxygen causes the ductus arteriosus to constrict. •The ductus arteriosus closes gradually as oxygenation improves.

Interatrial Septal Defects

Are usually from a failure of the foramen ovale to close.

Hypoxemia

An arterial pressure that is less than normal and can be identified by a decreased arterial oxygen saturation.

Treatment of Congestive Heart Failure

Correcting the problem as soon as possible.

Fetal Circulation

1 Umbilical Veins. Fetal venule. Fetal arteriole. 2 Umbilical arteries *Note that the color of fetal blood is reversed in the fetal vessels*

Aortic Stenosis Management

1. Aortic balloon valvulopasty: decrease stenosis and improves cardiac output. 2. Surgical Valvulotomy 3. Aortic valve replacement.

Coarctation of the Aorta Signs and Symptoms

1. Bounding pulses and elevated BP in the arms. 2. Decreased BP in the lower extremities. 3. Cool skin of lower extremities. 4. Weak or absent femoral pulses. 5. Heart failure in infants. 6. Dizziness, headaches, fainting, or nosebleeds in older children.

2 things that occur in Congenital Heart Disease

1. Congestive heart failure. 2. Hypoxemia.

Treatment of Congestive Heart Failure: Improve Tissue Oxygenation

1. Cool humidified oxygen. 2. Oxygen hood with young infants. 3. nasal cannula or face tent for older infants and children.

Coarctation of the Aorta Treatment

1. Diuretics and Digoxin to improve cardiac output. 2. Balloon catheterization. 3. Surgery: end to end anastomosis, use of prothetic patch, and left subclavian artery patch

Fetal Blood Flow

1. Oxygenated [red] blood flows from the placenta via umbilical vein in the umbilical cord.

Ventricular Septal Defect Surgical Treatment

1. Patch closure. 2. Banding.

Congenital Heart Problem: Obstructive or Stenotic Lesions

1. Pulmonary stenosis. 2. Aortic stenosis. 3. Coarctation of the aorta.

Birth and Stimuli for the First Breath

1. The sudden cooling as the child is born triggers the 'gasp' reflex. 2. Hypoxia and hypercapnia may occur during birth. 3. The breathing rhythm is immediate or begins after brief delay due to increased hypoxia. Delays of eight minutes are maximum tolerable.

Ventricular Septal Defect Medical Management

1. Treat CHF with Digoxin and Diuretics. 2. Nutritional supplements to increase calories. 3. Cardiac catheterization.

Fetal Structure: Umbilical Veins

2 Umbilical Arteries: becomes lateral umbilical ligament after birth. 1 Umbilical Veins: becomes round ligament of the liver.

Fetal Blood Flow

2. Oxygenated [red] blood from the umbilical vein continues as the ductus venosus within the liver, and joins the inferior vena cava. It mixes with the "blue" deoxygenated blood within the vena cava. From this point, the blood that oxygenates the fetal tissues is mixed blood.However, the fetal hemoglobin is able to pick up oxygen at a lower PO2.

Fetal Blood Flow: How blood bypasses the lungs

3a. The ductus arteriosus is a short, wide artery that connects the pulmonary trunk artery with the aorta. This allows most blood to bypass the lungs, although some blood still enters the right and left pulmonary arteries. There is considerable resistance to blood flow into the lungs because they are collapsed.

Fetal Blood Flow: How blood bypasses the lungs

3b. Before birth, the pressure in the right heart is greater than the pressure in the left heart. Because of this, the one-way valve, the foramen ovale, lets blood bypass the lungs by going from the right atrium to the left atrium.

Fetal Blood Flow

6. The umbilical veins carries red blood from the placenta (mom) to the fetus. There's 1 umbilical vein (rich supply from mom). There's 2 arteries (mixed blood from baby).

Patent Ductus Arteriosus

4. Bounding pulses. 5. Heart can be enlarged on CXR and infant will have tachypnea, poor feeding, and weight gain. 6. Frequent respiratory tract infections and fatigue.

Fetal Blood Flow

4. Mixed arterial blood flows through the same arteries as in the adult to oxygenate the tissues. Used, "blue" blood leaves via the same veins as in the adult and enters the superior or inferior vena cava.

Fetal Blood Flow

5. Mixed blood in the internal iliac arteries is sent out the two umbilical arteries through the umbilical cord to the placenta, where it becomes red, oxygenated blood. It also picks up nutrients and releases wastes.

Tricuspid Atresia

A complete closure of the tricuspid valve that results in mixed blood flow. An atrial septal opening is present that allows blood to enter from right atrium to the left atrium.

Treatment of Congestive Heart Failure: Improve Cardiac Function

Cardiac Glycoside: Lanoxin digoxin. ACE inhibitors: Capoten captopril and Vasotec enalapril *Infants and young children is not given if pulse is less than 90-110*

Circulatory Readjustments After Birth

A. Since blood no longer circulates in the placenta, blood volume in the child increases, causing increased pressure in the left ventricle, left atrium, and aorta.

Atrial Septal Defect

Abnormal opening between the atria, allowing blood from the higher pressure left atrium to flow in the lower pressure right atrium

Ventricular Septal Defect

An abnormal opening between the right and left ventricles which vary is size from a small pinhole to complete absence of the septum which can result in one common ventricle.

Diagnosis of Congestive Heart Failure

Based on clinical history. Physical examination: auscultation. Chest X ray. EKG and Echocardiogram. ABGs. Serum electrolyte. CBC.

Circulatory Readjustments After Birth

B. Pulmonary resistance decreases five times as the lungs expand with air, because the blood vessels are less compressed. Also the extra O2 causes vasodilation within the lungs. This decreases the pulmonary blood pressure, right atrium, and right ventricular pressures.

Fetal Structure. Umbilical cord

Becomes Umbilicus after birth

Tricuspid Atresia Signs and Symptoms

Cyanosis with decreased pulmonary blood flow, dyspnea, tachycardia, hypoxemia, clubbing of fingers, single second heart sound because of no closure of the tricuspid valve.

Circulatory Readjustments After Birth

D. Closure of the ductus arteriosus: the smooth muscle wall of the ductus arteriosus constricts due to the higher O2 availability, and closes fully within 1 to 8 days. Within one to four months, it is replaced with fibrous tissue and becomes ligamentum arteriosus.

Tetralogy of Fallot

Four defects that result in mixed blood flow. 1. Ventricular septal defect. 2. Pulmonary stenosis. 3. Overriding aorta. 4. Right ventricular hypertrophy.

Pulmonary atresia with intact ventricular septum

Desaturated blood flows through the tricuspid valve to the right ventricle but cannot enter the pulmonary artery because there is no pulmonary valve

Fetal Structure: Bypass of the liver

Ductus Venosus: becomes ligamentum venosum.

Fetal Structure by passes of the lungs

Ductus arteriosus: becomes ligamentum arteriosus. Foramen Ovale: becomes Fossa ovalis

Circulatory Readjustments After Birth

F. If it's not immediately cut, the umbilical cord may pulse for a few minutes after the birth but before the placenta detaches from the uterine wall. Even if the cord is not clamped, blood leakage from the cord will stop due to wharton's gel within it that swells upon exposure to air.

Circulatory Readjustments After Birth

E. Closure of the ductus venosus cont: This forces portal blood through the liver. The cause is unknown. The ductus venosus becomes the ligamentum venosum.

Ligamentum Venosum

Fibrosis of DV occurs by 1 week after birth and becomes the ligamentum venosum.

Circulatory Readjustments After Birth

G. The lack of blood flow to the wall of the umbilical arteries and vein causes fibrosis of them. The arteries become the lateral umbilical ligaments and the vein persists as the round ligament of the liver.

Aortic Stenosis

It is a narrowing or stricture of the aortic valve causing a resistance to the blood flow in the left ventricle and decreased output.

Atrioventricular Septal Defect Partial

Left to right shunting of blood with increased pulmonary blood flow related to difference in aortic and pulmonary pressure.

Aortic Stenosis Signs and Symptoms

Left ventricular hypertrophy, pulmonary congestion, chest pain, dizziness, syncope, faint pulses, intolerance to exercise, possible ejection murmur.

Atrioventricular Septal Defect Complete

Markedly increased pulmonary blood flow with associated pulmonary hypertension and risk for pulmonary vascular disease. Mixture of saturated and desaturated blood as pressure change and right to left shunting occurs.

Nursing Care Post Procedural Heart Catheterization

Monitor for signs of complications: Pulse, temperature and color of extremity, vital signs, blood pressure, dressing, fluid intake.

The First Breaths

Much extra effort is needed for the first breath. The child can produce more than twice the effort needed. Normal compliance is established about 40 minutes after birth.

R sided failure

Systemic overload, distention of the neck, peripheral edema.

Pressure and Saturation

O2 Pressure Adults: 80-100mmHg. O2 Pressure Newborn: 60-70mmHg. O2 Saturation Adults: 95-100 percent. O2 Saturation Newborn: 40-90 percent.

Pulmonary Stenosis

Obstruction of the blood flow from the right ventricle into the pulmonary artery

Interventricular Septal Defect

Occurs early in development; there is no normal opening in the interventricular septum before birth. Because the pressure in the left heart is higher than in the right heart after birth, the blood flows from the left side to the right side, increasing the work load on both sides of the heart.

Septal Defect [Hole in the Heart]

Occurs when either the interatrial or interventricular septum has a congenital perforation.

Fossa Ovale

Permanently closed foramen ovale several months after birth.

Pulmonary atresia with intact ventricular septum Signs and Symptoms

Profound cyanosis

Signs and Symptoms of CHF

Respiratory: Tachycardia [>60], tachypnea [>60], grunting, nasal flaring, rales, wheezes, or cough. Appearance: Facial/eye edema, neck vein distention, enlarged liver and spleen, and decreased peripheral perfusion and output.

Polycythemia and Clubbing

Result from chronic hypoxemia

Diagnostic Heart Catheterization

Right side: venous [right atrium]-most common in children. Left side: arterial [left ventricle]

Signs and Symptoms of CHF

Skin: Mottling, cyanosis pallor. Energy: lethargic, irritable, fatigued

Patent Ductus Arteriosus

Symptoms depends on the amount of left to right shunting. 1. Asymptomatic or show signs of CHF. 2. Characteristic machinery-like murmur called a continuous murmur 3. Widened pulse pressure [difference between systolic and diastolic pressure]

Signs of Heart Failure

Tachycardia, cardiomegaly, gallop rhythm, decreased peripheral perfusion, excessive diaphoresis, weight gain, ascites, liver and spleen enlargement, edema, neck vein distention, dyspnea, rales, tachypnea, intercostal and sternal retractions, and wheezing.

Stroke Volume

The amount of blood ejected by the heart in may one contraction.

Ligamentum Arteriosum

The ductus arteriosum permanently closes by 3 to 4 weeks and becomes the ligamentum arteriosum.

Ductus Venosus

The ductus venosus directs approx half of the blood flow from the umbilical vein away from the lover directly to the inferior vena cava. After birth, very little blood enters the ductus venosus.

Pediatric Congestive Heart Failure

The inability to maintain cardiac output sufficient to meet the metabolic demands of the body. Occurs most frequently secondary to congenital heart defects in which there is structural abnormalities. This results in increased volume or increased pressure on the ventricles.

Cardiac Output

The volume of the blood ejected by the heart in one minute.

Patent Ductus Arteriosus Surgical Treatment

Visual assisted throracoscopic surgery VATS

Patent Ductus Arteriosus Medical Treatment

1. Indocin-indomethacin drug. 2. Digoxin lanoxin and Diuretics to control CHF. 3. Conserve energy and prevent exposure to respiratory infections. 4. Heart catheterization.

Treatment of Congestive Heart Failure: Remove Accumulated Fluid

1. Diuretics: furosemide lasix, chlorothiazide diuril, spironolaction aldactone, bumetanide bumex, metolazone zaroxlyn. 2. Fluid restriction. 3. Sodium restricted diet.

Congenital Heart Disease: Genetic Factors

1. Down syndrome 50% 2. Turner syndrome [missing X on female] and Klinefelter syndrome [extra X on a male]. 3. DiGeorge syndrome. 4. Marfan Syndrome: connective tissue problems, long limbs.

Nursing Care Pre Procedural Heart Catheterization

1. History and assessment. 2. Baseline O2 sat level. 3. Patient and Family education. 4. Administration of medications. 5. Allergies/on going Infection. 6. Marked pedal pulses. 7. NPO at midnight.

The Goals of Treatment of Congestive Heart Failure

1. Improve cardiac function: to increase contractility and decrease afterload. 2. Remove accumulated fluid: decrease preload. 3. Decrease cardiac demands. 4. Improve tissue oxygenation and decrease oxygen consumption.

Congenital Heart Problem: Left to Right Shunting Lesion

1. Patent ductus arteriosus. 2. Atrial septal defect. 3. Ventricular septal defect. 4. Atrioventricular septal defect.

Treatment of Congestive Heart Failure: Decrease Cardiac Demand

1. Prevent cold stress in infants. 2. Treat existing infections. 3. Reduce the effort of breathing: semi-fowlers position. 4. Provide rest.

Tetralogy of Fallot Treatments

1. Prostaglandin infusion to maintain patency of the ductus arteriosus and blood flow to the lungs. 2. Management of hyper cyanotic episodes. 3. Treatment of iron deficiency anemia. 4. Surgery: primary repair of defects during infancy is the procedure of choice. Surgery occurs after 4 months of age.

Tricuspid Atresia Treatment

1. Prostaglandin transfusion to maintain patency of the ductus. 2. Balloon atrial septostomy. 3. Catheter blade sptostomy to cut the septum tissue, if balloon septostomy is not effective.

Congenital Heart Problem: Cyanotic Lesions with Decreased Pulmonary Blood Flow

1. Tetralogy of fallot. 2. Tricuspid atresia. 3. Pulmonary atresia with intact ventricular septum.

Coronary Heart Angiogram/Catheterization

Approach from the Left side [arterial]

Fetal Blood Flow

3. The lungs are collapsed and nonfunctional; they receive only enough blood for their own growth. most of the blood bypasses the lungs in one of two ways.

Pulmonary Stenosis Signs and Symptoms

Asymptomatic. Mild cyanosis. Congestive heart failure. Cardiomegaly. Exercise intolerance. Systolic ejection murmur.

Circulatory Readjustments After Birth

C. Foramen ovale closure: This one-way valve between left and right atria closes due to the increase in left heart pressure and the decrease in the right heart pressure. It only allowed right to left blood flow before birth.

Pulmonary Stenosis Medical Treatment

Cardiac observation and antibiotic prophylaxis. Balloon valvuloplasty (catheterization) Surgical valvulotomy. Placement of a shunt from aorta to pulmonary artery for critical pulmonary stenosis.

Coarctation of the Aorta

Localized narrowing of the lumen of aorta near the insertion of the ductus arteriosus, resulting in increased pressure proximal to the defect--head and upper extremities-- and decreased pressure distal to the obstruction--body and lower extremities--.

Patent Ductus Arteriosus

Occurs when the ductus arteriosus fails to close after birth. The blood recirculates from the aorta to the pulmonary trunk --higher pressure to lower-- and causes more work for both sides of the heart. It may be corrected with medications, or may be surgically corrected.

Ductus Arteriosus

•Functional closure occur within 15-24 hours. Until close is complete, the blood that does flow through the vessel reverses, moving from the aorta to the pulmonary artery and increasing blood flow to the lungs.

Placenta

•It is a source of nutrients to the fetus, and it removes wastes. •It provides maternal antibodies to the fetus [IgG]. •The placenta serves as the lungs, digestive system, kidneys, immune system of the fetus. •It is also a major source of reproductive and other hormones during pregnancy.

Foramen Ovale

•Little mixing occurs with the less oxygenated blood that enters from the superior vena cava and continues to the right ventricle. •Most of the better oxygenated blood travels away from the non functioning fetal lungs.

Foramen Ovale

•The foramen ovale is functionally closed soon after birth because pressure changes in the heart prevent it from opening. Conditions such as asphyxia, however, may reverse the pressures in the heart and cause the foramen ovale to reopen.

Foramen Ovale

•The foramen ovale opens only from right to left. The higher pressure in the right side of the heart caused by the restricted flow of blood to the lungs causes this right to left shunting.

Foramen Ovale

•The pressure in the right side of the heart decreases at birth when the umbilical vessels are occluded and blood flows easily into the pulmonary circulation.

Ductus Arteriosus

•This sequence occurs because pressure in the aorta is now higher than that in the pulmonary artery. A murmur may be heard as a result of blood flow through the partially open vessel.

Placenta

•Vascular organ, genetically part maternal and part fetal. •It enables maternal and fetal blood to flow close by one another, separated only by permeable membranes. •Maternal and fetal blood do not mix, but placenta allows for exhngage of oxygen and carbon dioxide.