Abstract
Objectives
The management of patent ductus arteriosus (PDA) in neonates is a contentious issue with variations between many centres. Does timing PDA management prophylactically, fare better than waiting for haemodynamic compromise? Are medical approaches safer and more effecitve than an interventional approach? How should medical or surgical interventions be approached? Should clinicians intervene at all? This review aims to navigate through the current literature.
Method
Keywords "Patent ductus arteriosus", "neonate", "premature", "preterm" and "low birth weight" were searched on PubMed, the Cochrane Library and Medline. Referenced articles were also included. Outcome measures such as time to closure, rate of closure, morbidity and mortality were observed.
Result
Studies observing conservative management showed that PDAs close spontaneously in up to 73%. Complication rates in conservative management compared to indomethacin use were similar, with conservative measures taking longer to reach closure. Indomethacin was shown to have better outcomes when used prophylactically compared to symptomatic cases. However, paracetamol and oral ibuprofen was shown to be safer than indomethacin in symptomatic patients with less renal and gastrointestinal effects. Successful medical management was demonstrated to be dependent on ductal diameter and gestational age. Outcomes following prophylactic surgery were similar to those undergoing conservative management. Morbidity and mortality were similar in those undergoing percutaneous occlusion and open ligation.
Conclusion
Many studies were observational, retrospective, single-centre studies and had not reported important outcome measures. Robust evidence from randomised, multi-centre studies are needed, as well as studies comparing treatment disciplines. Future studies should look to report long-term outcome measures.
Take-home message
Despite the range of studies meta-analyses available, there is a lack of robust and definitive evidence out there to suggest when and how to approach a PDA in premature/low-birthweight neonates which is reflected in the heterogeneity of management options for PDA patients between different centres. Observational studies show that conservative management, management using paracetamol and an interventional approach (either thoracotomy or endovascular) are all viable options, however the lack of randomised, interventional studies fail to show which method is superior.
Is surgical ligation of patent ductus arteriosus necessary? The Western Australian experience of conservative management
