Vol.-2, no.-1, july 2009 cardio vas j.pmd

Misoprostol Increase Oxygen Saturation in Duct
Dependent Congenital Heart Disease
ABMA Salam
Department of Paediatric Cardiology, NICVD, Dhaka. Abstract:
Background: Duct (PDA) dependent congenital heart disease is a spectrum of serious congenital
Keywords-
problems which needs urgent prostaglandin therapy before palliation or definite treatment otherwise chances of mortality & morbidly is very high. As, parenteral form of the drug is very costly, not easily available & maintenance is not possible, so, we used oral synthetic analogue Misoprostol for the patency of PDA.
Methods: A double-blind case control study involving 50 case & 50 control patients of duct dependent
congenital cyanotic heart disease were enrolled. Pulse oxymetry (SPaO2) were done in each case.
Case group were given oral misoprostol & control were given placebo. Results: Misoprostol was found to increase oxygen saturation in duct dependent CHD.Chai square
test (p<0.05) & paired “t” test (<0.001) were significant.
Conclusion: We conclude that oral misoprostol can be used in duct dependent congenital heart
disease with efficacy & safety.
(Cardiovasc. j. 2009; 2(1) : 20-22)
Introduction:
Methods:
Duct (PDA) dependent congenital heart disease is • Diagnosis was made with detail Echo-color- a spectrum of serious congenital problems. These Doppler studies. History & clinical examination are Pulmonary Atresia, TGA with IVS, Severe TOF, Tricuspid Atresia with severe pulmonary stenosis, Hypoplastic Right Heart syndrome, TAPVC with • Inclusion criteria: Duct (PDA) dependent intact septum, Critical PS, Severe Coarctation of congenital heart diseases having lower than Aorta, Hypoplastic Left Heart Syndrome.1 These are very difficult to manage & ever challengingboth for the pediatric cardiologist & as well as for • Exclusion criteria: Isolated PDA or with other pediatric cardiac surgeons particularly in a neonate & very young infant. Medical therapy includes the use of parental prostaglandin E1 Infusion as an • Patients sample were randomized into two emergency treatment for the maintenance of PDA groups in double blind way. Baseline oxygen flow.2 But, parental form of prostaglandin E1 is saturation of all patients was recorded in a very costly (>USD200/ampoule), rarely available, preferentially should be given in ICU setting & • 50 cases were given oral Misoprostol, (25 long term maintenance is not possible. So, a cheap, microgram/kg body weight in 4 divided doses) easily available, oral form of the drug was the long & another group was given placebo.
time demand of the clinicians. Misoprostol, asynthetic oral analogue of prostaglandin E1 is now • Effects were observed within 8-24hrs & follow available & we used this drug in duct dependent up monitoring with pulse oxymetry (SPaO2) congenital heart disease to increase their oxygen were done & recorded for 2 months to 12 months saturation maintaining patency of PDA. This was • All the patients were closely monitored for a prospective double blind case-control prospective temperature, respiratory rate, pulse, blood study involving 100 cases of duct dependent pressure, neurological assessment, glycemic & Address of Correspondance: Dr. A B M Abdus Salam, Department of Paediatric Cardiology, NICVD, Dhaka, Bangladesh.
Misoprostol Increase Oxygen Saturation in Duct Dependent Results:
Data were compiled & statistical analysis was done with standard tests. Age, sex & disease • Chai square test was applied & found significant distributions are shown in the following fig-1, 2 & Efficacy of Misoprostol on O saturation in patients with duct dependent congenital heart disease. Fig.-1: Age distribution
Comparison of oxygen saturation (SPaO2) before& after administration of Misoprostol- • Mean SPaO2 before Misoprostol= 63±11% • Mean SPaO2 after Misoprostol= 79± 13% • Paired‘t’ test was applied to the data of base line saturation before Misoprostol & theaverage increase in saturation afterMisoprostol.
• ‘t’ = 4.819, which at df of 49, p value is <0.001.This means the result of this study is Fig.-2: Sex distribution
• So, the drug is highly effective to increase oxygen saturation in duct dependent congenitalheart diseases Fig.-4: %Spao2 before (b) & after (a) Misoprostol
Complications:
Fig.-3: Disease Distribution
P.at - Pulmonary atresia. TOF- Tetralogy of Fallot, Tr.at- bradycardia, hypotension, seizure were seen.
Tricuspid atresia. TGA- Transposition of great arteries, C.PS- Congenital pulmonary stenosis, AV-can- AV canal defect,HL- Hypoplastic left ventricle, C.ao- Coarctation of aorta Outcome:
• The patients of both case & control groups who achieved & maintained oxygen saturation more Discussion:
than 70% was considered as improved group.
Duct dependent congenital heart diseases are night • But who did not achieve that saturation rather mare for the pediatric cardiologist. Closure of PDA after birth is due to sudden fall in prostaglandin, high oxygen concentration & increase in pH. 3 In with large sample size to prove its efficacy & duct dependent CHD, urgent prostaglandin E1 administration should be given immediately formaintenance of PDA flow, so that the patient can survive & go for definitive surgical orinterventional procedures 4. Prostaglandins E References:
series of AA metabolites causes direct dilatation Robert M F. Pulmonary Atresia with intact ventricular of PDA. 5 Misoprostol is a synthetic oral analogue septum, Moss & Adams’s text book of Heart disease in of prostaglandin E1 & it has same mechanism of infants, children and adolescents: 5th edition, volume actions on the different sites as it was proved in various human studies. 6,7,8 So we aimed to use Saxena A, Sharma M, Kothari S, and Juneja R et al.
this drug in PDA dependent CHD to see its effects.
Prostaglandin E1 infusion in infant with congenital In our study, we found less morbidity and mortality heart diseases – Indian experience. Indian Pediatrics (p<0.5) with significant (p<0.001) increase in SPaO2 in case group than in control group (table -1,table Fuster V, Alexander WR et al. Patent Ductus -2 & fig-4).We observed minimum side effects of Arteriosus: Hurst’s text book, The Heart, International the drug. Long term maintenance oral therapy is edition, volume-2, chapter-33: page-1858.
possible until the patient become fit for the William T. Dungan. Prostaglandin E1 in Infants with critical congenital heart diseases. The Journal of Conclusion:
Keneth M, Wosener MD. Haemodynamics effects of • As we found definitive increase in SPaO2 along PGE1 in patients with congenital heart disease.
with clinical well being of the duct dependent Catheterization & cardiovascular diagnosis; 24: 10-15.
congenital heart disease without any major Melilo E, Wooley KL, Manning PJ, et al, Effects of adverse effects in a double blind case-control inhaled PGE 2 on exercise induced bronchoconstriction study, we recommend Misoprostol to be used in Asthmatics subjects. American Journal of in this condition. Because it is cheap, easily Respiratory and Critical Care Med 1994; 149: 1138-41.
available & can be given at home setting. It Plaut MM, Schwartz ML, Lubarsky S. Uterine rupture may be used as a maintenance therapy after with use of Misoprostol in gravid patient with previous initial prostaglandin E1 infusion where it is cesarean section. American Journal of Obstetrics & Gynecology 1999 (Jun); 180: 1535-42.
Kailasam MT, Lin MC, Ceven JH, et al. Effects of oral Recommendation:
prostaglandin E1 agonist on blood pressure and its • As the sample size was low, we recommend determinants in essential hypertension. Journal of further multi-centre & multi-national studies Human Hypertension 1994: 515-20.

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