PERUBAHAN FISIOLOGIK BBL

Dian Angraeni
 PENDAHULUAN
• Transisi neonatal memerlukan pernafasan
spontan & perubahan kardiopulmonal yang
tidak tergantung pada kematangan fungsi
organ.

• Pengetahuan yang baik mengenai transisi

neonatus akan membantu memahami bahwa
neonatus mengalami kesulitan pada saat lahir
 Fisiologi Kardiovaskuler Fetus
• Ventrikel kanan & kiri memiliki tugas yang
sama pada fetus & neonatus
• Hanya 1 ventrikel yang diperlukan untuk
stabilitas kardiovaskular🡪 V ka
• Ukuran & bentuk struktur kardiovaskular
tergantung pada pola aliran & valume darah
yang melaluinya
 Fisiologi Kardiovascular Fetus
• V. Umbilical membawa
darah kaya O2 dari
placenta ke fetus
• Aliran darah terbagi pd
porta hepatis
– 50-60% to IVC
– Remainder to portal
circulation
– Perfuses liver then
passes into IVC
Fisiologi Kardiovascular Fetus
Fetal Cardiovascular Physiology
• 25% total aliran balik
vena melalui foramen
ovale to atrium kiri
• Darah yang kurang
tersaturasi dari V Ka
melalui A. Pulmonalis
– 12% ke V pulmonar
– Selanjutnya ke Ao Desc
via PDA ke leher,
abdomen, lower
extremities, and
umbilical artery
 Fetal Cardiovascular Physiology
• Highly oxygenated
output from LV
passes into
ascending aorta
– Perfuses heart,
brain, head, and
upper torso
 Fetal Cardiovascular Physiology

In the fetus
● Arterioles are
constricted
● Pulmonary blood
flow is diminished
● Blood flow is
diverted across
ductus arteriosus
 Fetal Pulmonary Physiology

• Placenta provides respiratory function for fetus

• Multi-villous circulation
• Allows maximum maternal/fetal blood exposure
• Lower maternal pH
• Results in increased transfer of oxygen by
maternal and fetal hemoglobins
 Fetal Pulmonary Physiology

• Alveolar development nearly complete at 34wk

• Surfactant systems begin to mature @ 34wk
• Fetal lung is filled with approximately 20ml/kg
fluid at term
• Because of compressive effect of lung fluid and
low PaO2 , pulmonary capillary vessels remain
constricted
 Fetal Pulmonary Physiology

• Successful transition to extra-uterine life

requires rapid clearance of fetal lung fluid
• Process begins 2-3 days before labor with a
decrease in the rate of secretion to 1-2
cc/kg/hr
• Catecholamine release during labor decreases
secretion and also facilitates resorption
Transition to Extrauterine Life
 Intrauterine to Extrauterine Life

• The transition period is defined as the moment

from birth to 6 hours of age
• It is a process of multiple physiological changes
• Begins in utero as infant prepares for delivery
 Intrauterine to Extrauterine Life

Fetus prepares for transition throughout

gestation:
• Storing glycogen
• Protein and mineral accretion
• Deposition of brown fat as energy store
• Ability to accomplish this depends on
gestational age & quality of the placenta
 Intrauterine to Extrauterine Life

• First few hours are a time of stabilization of

the newborn’s, respiration, cardiovascular
dynamics and temperature
• Occur almost simultaneously
• Close clinical observation identify those
infants unable to make a successful
transition
 Intrauterine to Extrauterine Life

Key components of successful

Extrauterine adaptation:
• Lung expansion
• Initiation of gas exchange
• Closure of circulatory shunts
 Birth

• Loss of umbilical life line

• Fetus becomes self-sustaining,

Air-breathing infant
 Respiratory Adaptation
For the lungs to operate as a functional
respiratory unit providing adequate gas
exchange after birth:
• Airways and alveoli must be cleared of fetal lung
fluid
• Lung expansion and increase in pulmonary
blood flow must occur
• Within minutes, the pulmonary vascular
resistance may decrease by 8 to 10 fold, causing a
corresponding increase in pulmonary blood flow
 Respiratory Adaptation
Fetal lung fluid
• Rate of formation of lung fluid begins to
decrease days prior to birth
• Only a portion removed physically during
delivery:
– “Thoracic squeeze” may account for < 15%
reduction,
– Thoracic recoil allows for passive inspiration
of air into the alveoli driving fluid into
capillary spaces
 Respiratory Adaptation
• Effective transition requires that any remaining liquid be
quickly absorbed to allow effective gas exchange
• Decrease in lung fluid begins before labor
• Labor is associated with increased catecholamine levels
that stimulate lymphatic drainage of the lung
• lung fluid volume at birth is decreased in infants whose
mothers have labored
• After birth, lung fluid is removed by several mechanisms,
including:
• active ion transport,
• passive movement from Starling forces, and
• lymphatic drainage
 Respiratory Adaptation

Lung expansion
Lung expansion requires overcoming forces
which resist expansion:
• Viscosity of fetal lung fluid
• Lung compliance
• Surface tension forces established at air- liquid
interfaces
 Respiratory Adaptation
• First breath - diaphragm generates negative
intrathoracic pressure to begin aeration of
collapsed alveoli
• Must generate high trans-pulmonary pressure
– To overcome the viscosity of lung fluid and the
intra-alveolar surface tension
– Drive fluid across alveolar epithelium
• Alveolar lining layer becomes established
• Molecules of surfactant are released from type
II lung pneumocytes
 Respiratory Adaptation

• Surfactant decreases surface tension

• Alveolar radii expand
• Sequential breaths require less
transpulmonary pressure
 Respiratory Adaptation
• With subsequent aeration, intraparenchymal
structures stretch and gasses enter alveoli
– Results in increased pH and PaO2
– Pulmonary vasodilation
– Constriction of the ductus arteriosus
• Increased PaO2 may be responsible for
development of continuous breathing via
hormonal or chemical mediators
 Respiratory Adaptation
Pulmonary vasculature is stimulated to dilate by
several mediators:
• Nitric oxide is released when pulmonary blood
flow and oxygenation increases
• Prostaglandin formation is induced by the
presence of increased oxygen tension
– Acts on pulmonary smooth muscle bed to induce
pulmonary vasodilation
 Respiratory Adaptation

Lung expansion and aeration is a stimulus

for surfactant release:
• Development of air-fluid interface
• Development of functional residual capacity
– In term neonates, 80-90% of FRC established
within first hour of birth
 Postnatal Changes in Circulation

• Circulation in utero - system in parallel

• Circulation changes to two distinct blood
flow systems - in series
Circulatory Adaptation
• Pulmonary blood
flow increases
dramatically
• Central blood flow
patterns are
significantly altered
• Combined
ventricular output
increases greatly
 Circulatory Adaptation

• Clamping of umbilical cord removes low

resistance placental vascular circuit
– increase in total vascular resistance
– increase in left ventricular and aortic pressures
• Pulmonary vascular resistance decreases
– Dilation of pulmonary vessels by chemical
mediators
– Decompression of the capillary lung bed
 Circulatory Adaptation

• Decrease pulmonary artery pressures leads

to increase in pulmonary blood flow and
pulmonary venous return
• Increased SVR combined with decreased PVR
reverses the shunt through the PDA until it
completely closes
 Circulatory Adaptation

Other fetal shunts

• Due to changes in atrial pressures, the “flap-like”
foramen ovale is pushed closed against the atrial
septum
– Anatomical closure typically occurs around several
months of age
• Ductus venosus closes when clamping of cord
terminates umbilical venous return
– Functional mechanical closure by collapse of thin-
walled vessels
– Anatomical closure at 1-2 weeks of age
 Circulatory Adaptation

• Constriction and closure of PDA accomplished

by contractile tissue within walls
• Dependent upon increase in PaO2 and a fall in
circulating PGE-2
• Functional closure within 72 hours of life
• Anatomical closure by 1-2 weeks of age
 Circulatory Adaptation

• PVR & pulmonary artery pressure continue to

fall over the first 6 - 8 weeks of life secondary
to regression of the medial muscle layer over
the arteries
• PVR falls within 2 - 3 weeks in premature
infants due to less medial muscle layer
development
 Circulatory Adaptation
• Primary change is a shift in blood flow from
placenta to lungs as the organ of gas
exchange
• Once ventilation is established, vascular
pressure in lungs has decreased, & the
ductus arteriosus has closed - the lungs
receive the same proportion of cardiac
output that the placenta had received
 Relationship between Pulmonary &
Cardiovascular Changes
After delivery
●Lungs expand with air
●Fetal lung fluid leaves alveoli

© 2000
 Relationship between Pulmonary &
Cardiovascular Changes
After delivery
●Pulmonary
arterioles dilate
●Pulmonary blood
flow increases

© 2000
 Relationship between Pulmonary &
Cardiovascular Changes

After delivery
● Blood oxygen levels
rise
● Ductus arteriosus
constricts
● Blood flows
through the lungs
to pick up oxygen

© 2000
 What Can Go Wrong
During Transition?

● Insufficient ventilation,
● Sustained constriction of pulmonary
arterioles
 Failure to Transition

Impaired alveolar expansion

and clearance of fetal lung fluid

Sustained high PVR

Hypoxia
 Failure to Transition
Impaired alveolar expansion and clearance of
fetal lung fluid
• Apnea at birth with no respiratory effort
• Shallow ineffective respirations
– Prematurity / surfactant deficiency
– Asphyxia / sedative drugs in labor
– Abnormal lung development
– Retained lung fluid
– Meconeum Aspiration Syndrome
 Failure to Transition
Sustained high PVR
• Impaired alveolar expansion
• Pulmonary vascular maldevelopment
– Diaphragmatic Hernia
– Pulmonary hypoplasia
– Chronic Intrauterine hypoxia
– Alveolar capillary dysplasia
• Pulmonary vasoconstriction
– Sepsis with cytokine release
– Maternal use of NSAID
Interruption of Normal Transition:
Apnea

Primary apnea
● Rapid attempts to breathe
● Respirations cease
● Heart rate decreases
● Blood pressure is usually maintained
● Responds quickly to stimulation

© 2000
 Secondary Apnea
Secondary Primary Secondary
Apnea apnea apnea
● Respirations cease
● Heart rate
decreases Respirations

● Blood pressure
decreases
Heart
rate

● No response to
pressure
Blood

stimulation

© 2000
Signs of a Compromised Newborn

● Cyanosis
● Bradycardia
● Low blood
pressure
● Depressed
respiratory effort
● Poor muscle tone
© 2000
 Retained Lung Fluid
• Usually follows uneventful normal term
vaginal or cesarean delivery

• Characterized by
– Early onset of tachypnea, sometimes with
retractions or expiratory grunting
– Occasionally, cyanosis relieved with minimal
oxygen
 Retained Lung Fluid

• Lungs generally clear

• Chest X-ray
– Prominent pulmonary markings
– Fluid lines in fissures
– Over-aeration, Flat diaphragms
– Occasionally, pleural fluid
 Delayed Transition

• Believed to be secondary to slow absorption

of fetal lung fluid resulting in
– Decreased pulmonary compliance and
expansion
– Increased dead space
• Often difficult to distinguish from sepsis if
other risk factors present
 Retained Lung Fluid
• Self-limiting disease
– Usually recover rapidly within 1-3 days

• Supportive care
– Supplemental oxygen
– May need ventilatory support
– Ambient temperature support
– IV fluid support
 Persistent Pulmonary HTN
• Occurs in near-term, term, and post-term
infants
• Persistence of fetal circulatory pattern of
right-to-left shunt through PDA and foramen
ovale after birth
– Due to excessively high pulmonary vascular
resistance
• Profound hypoxia with normal or elevated
PaCO2
 Persistent Pulmonary HTN
Predisposing factors

• Birth asphyxia • Maternal use of NSAIDs

• Meconium aspiration • Pulmonary hypoplasia
pneumonia • CDH
• Early-onset sepsis • Amniotic fluid leak
• RDS • Oligohydramnios
• Hypoglycemia • Pleural effusions
• Polycythemia
 Persistent Pulmonary HTN

• Hypoxia is quite labile and out of

proportion to findings on CXR
• Differential diagnosis:
– Cyanotic Heart Disease, especially TAPVR
 Persistent Pulmonary HTN
• Treatment
– Correct any underlying disease
– Correct acidosis, hypotension, and hypercapnia
• Mechanical ventilation/ optimal ventilation
• Blood pressure support / Pressors
• Optimal pH (Na bicarbonate)
– Improve tissue oxygenation
• Mechanical Ventilation / Oxygen
• iNO
• ECMO
 Physiologic Changes During Birth
• Most infants make a successful transition to
extra-uterine life
• Identify infants at risk of failure to transition:
– Premature
– Intra-uterine hypoxia / fetal distress
– MSAF
– IDM / SGA / IUGR
– Infants with malformations
 Physiologic Changes During Birth

• Provide optimal care to allow newborn

transition successfully
• Adequate airway
• Ensure adequate oxygenation and circulation
• Optimal thermal environment