CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 3, April 2013
72
AFRICA
Neonatal circulatory failure due to acute hypertensive
crisis: clinical and echocardiographic clues
JACOBA LOUW, STEPHEN BROWN, LIESBETH THEWISSEN, ANNE SMITS, BENEDICTE EYSKENS,
RUTH HEYING, BJORN COOLS, ELENA LEVTCHENKO, KAREL ALLEGAERT, MARC GEWILLIG
Abstract
Objective:
Circulatory failure due to acute arterial hyperten-
sion in the neonatal period is rare. This study was under-
taken to assess the clinical and echocardiographic manifes-
tations of circulatory failure resulting from acute neonatal
hypertensive crisis.
Methods:
Neonatal and cardiology databases from 2007 to
2010 were reviewed. An established diagnosis of circulatory
failure due to neonatal hypertension before the age of 14 days
was required for inclusion. Six patients were identified.
Results:
Five patients presented with circulatory failure due
to an acute hypertensive crisis. The median age at presen-
tation was 8.5 days (range: 6.0–11.0) with a median body
weight of 3.58 kg (range: 0.86–4.70). Echocardiography
demonstrated mild left ventricular dysfunction [median
shortening fraction (SF) 25%, range 10–30) and mild aortic
regurgitation in 83% (5/6) of patients. One patient with
left ventricular dysfunction (SF
=
17%) had a large apical
thrombus. Two patients were hypotensive, and hypertension
only became evident after restoration of cardiac output.
Administration of intravenous milrinone was successful, with
rapid improvement of the clinical condition. Left ventricular
function normalised in all survivors.
Conclusion:
Early neonatal circulatory collapse due to arte-
rial hypertension is a rare but potentially life-threatening
condition. At presentation, hypotension, especially in the
presence of a dysfunctional left ventricle, does not exclude
a hypertensive crisis being the cause of circulatory failure.
The echocardiographic presence of mild aortic regurgita-
tion combined with left ventricular hypocontractility in a
structurally normal heart should alert the physician to the
presence of underlying hypertension.
Keywords:
neonatal, shock, hypertension, crisis, echocardio-
graphy
Submitted 5/5/12, accepted 11/1/13
Cardiovasc J Afr
2013;
24
: 73–77
DOI: 10.5830/CVJA-2013-003
Circulatory failure is frequently the forerunner of a serious
underlying condition in the neonate. It requires rapid detection
of origin to differentiate non-cardiac (e.g. sepsis, metabolic
derangements) from cardiac causes. Echocardiography is
requested as an early diagnostic test, primarily with the intention
to exclude potentially lethal structural heart disease, for example
coarctation of the aorta, critical aortic stenosis, or hypoplastic
left heart. When left ventricular dysfunction is observed, the
focus shifts to myocardial disease. Acute episodes of systemic
hypertension are rarely, if ever, considered in the differential
diagnosis.
Very little is known about the incidence of acute hypertensive
crisis in newborn infants. Acute systemic hypertensive episodes
during this period are most likely under-recognised and under-
diagnosed. It is a rare but potentially life-threatening condition.
Systemic hypertension in neonates has a reported incidence
varying from 0.2 to 2.6%.
1-4
Cardiomegaly, hypocontractility, overt cardiac failure and even
death related to neonatal hypertension have been described but
consist mostly of a few case reports.
2,3,5-10
Successful management
relies on early and prompt recognition and treatment.
This study was undertaken to assess the clinical and
echocardiographic manifestations of circulatory failure resulting
from acute hypertensive events.
Methods
This was a retrospective review. To be considered for inclusion,
an established diagnosis of circulatory failure associated with
a blood pressure more than the 95th percentile for gestational
age and weight during the course of admission in the neonatal
intensive care unit before the age of 14 days was essential.
3
Neonatal and cardiology databases of a tertiary referral centre
from 2007 to 2010, consisting of 2 632 admissions to the
neonatal intensive care unit, were reviewed. Six patients with
circulatory collapse and documented systemic hypertension, as
defined, were identified.
Standard descriptive and demographic data were obtained
from patient records. Patient charts were reviewed for clinical
course, laboratory results and outcome. In order to eliminate
inter-observer bias, echocardiograms performed during the
initial presentation were digitally reviewed by a single paediatric
cardiologist and recalculated. The averages of previous and
recalculated measurements were used.
Paediatric Cardiology, University Hospitals Leuven, Leuven,
Belgium
JACOBA LOUW, MD
STEPHEN BROWN, MMed, FCPaed, DCH
BENEDICTE EYSKENS, MD, PhD
RUTH HEYING, MD, PhD
BJORN COOLS, MD
MARC GEWILLIG, MD PhD,
University of the Free State, Bloemfontein, South Africa
STEPHEN BROWN, MMed, FCPaed, DCH
Neonatology, University Hospitals Leuven, Leuven, Belgium
LIESBETH THEWISSEN, MD
KAREL ALLEGAERT, MD, PhD
Paediatric Nephrology, University Hospitals Leuven,
Leuven, Belgium
ANNE SMITS, MD
ELENA LEVTCHENKO, MD PhD
