Vol.-2, no.-1, july 2009 cardio vas j.pmd
Misoprostol Increase Oxygen Saturation in Duct
Dependent Congenital Heart Disease
Department of Paediatric Cardiology, NICVD, Dhaka.
Background: Duct (PDA) dependent congenital heart disease is a spectrum of serious congenital
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)
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
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
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
• The patients of both case & control groups who
achieved & maintained oxygen saturation more
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
concentration & increase in pH.
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
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
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
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 &
1999 (Jun); 180: 1535-42.
Kailasam MT, Lin MC, Ceven JH, et al. Effects of oral
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
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