Spectrum of Congenital Heart Disease in Neonates Admitted in an Intermediate Care Unit of a Tertiary Level Hospital

Introduction: Congenital Heart Disease is the most common cause of major congenital anomalies accounting 28.0%, representing a major global health problem. Prevalence of Congenital Heart Disease is 1.3 per 1000 in school children of Nepal.Material and Methods: A cross sectional prospective study was carried out in the neonatal intermediate care unit of Kanti Children’s Hospital, Nepal from Jan 2016 until Dec 2016 to see the spectrum of CHD.Results: Out of admitted 831 neonates, 85 were found to have CHD with prevalence of 102.28 per 1000 admitted neonate. Respiratory distress was the commonest symptom (51.8%) followed by cyanosis (11.8%) and reluctant to feed (10.6%) at presentation. ASD was the commonest (87.1%) cases followed by PFO 23.5%, PDA 21.2%, Complex congenital heart disease 11.8% and TOF 1.2%. Cleft lip and Cleft Palate was found in 5.9%, Down’s syndrome 3.5% of cases, polydactyly and syndactyly was detected in 2.4% newborn with CHD. The mode of delivery was spontaneous in 71.8% followed by Elective LSCS were 14.1% and Emergency LSCS were 9.4%.Conclusions: Prevalence of CHD was the 102.28 per 1000 neonates admitted in NIMCU. Atrial Septal Defect was the commonest congenital heart diseases. Cleft lip and Down’s syndrome were the most extra cardiac anomaly associated with CHD. Respiratory distress was the commonest presentation of CHD for hospital admission.


Introduction
C ongenital heart disease (CHD) is the most common cause of major congenital anomalies accounting 28.0%, representing a leading global health problem with prevalence in neonate of be 5-8/1000 1,2,3,4 .Studies done in Pakistan and India showed a prevalence rate of up to 4/1000 live births 5,6 .Literature review could not fi nd any prevalence study in neonates of Nepal as such, but some showed that the prevalence of CHD in school childrenwas1.3per 1000 and 5.8 per 1000 hospitalized patients 7,8 .Worldwide the prevalence of CHD has increased substantially from <1 per 1,000 live births in 1930 to 9 per 1,000 live births in recent years due to changes in diagnostic methods and screening modalities rather than representing a true increase 9,10 .Thus, the aim of this study was to fi nd out the spectrum and prevalence of CHD presented in a Neonatal Intermediate care unit of a tertiary care paediatric hospital of Nepal.

Material and Methods
This prospective study was carried out over a period of one year from January 2016 until December 2016 among the admitted neonate in the Neonatal Intermediate Care Unit (NIMCU) age ranging from newborn to 28 days.A thorough clinical examination was carried out within fi rst 24 hours of admission.Congenital Heart Disease (CHD) was suspected in the presence of following criteria defi ned by Mitchell et.al 1 .Presence of cardiac murmur, presence of cyanosis or feeding diffi culty only, cyanosis associated with feeding diffi culty, presence of congestive heart failure or failure to thrive.Detailed history was collected from parents or attendant regarding family history of congenital heart disease in siblings, parents.The questionnaire also enquired about; signifi cant history of ingestion of drugs, hormone, exposure to radiation, history of fever with rash prior six months of conceptions and in 1st trimester, maternal age and parity of the mother.The birth weight, age, sex and gestational age of babies were also recorded.All suspected patients were investigated by doing a chest X-ray and 2D, M-mode echocardiography with colour Doppler.Additional screening for babies of diabetic mothers, all babies with Down's syndrome and babies with congenital malformations were alsoscreened.

Results
There were 831 neonates admitted during the study period out of which 85 were found to have CHD.The prevalence was 102.28 per 1000 admitted neonates, se venty six (89.41%) were term and 9 (10.58%) were preterm.

Discussion
Congenital heart disease has already been recognized as one of the important risk factor for neonatal morbidity.Ferencz et.al. reviewed seven major studies from Europe and North America and concluded that confi rmed CHD prevalence had been remarkably constant at 4/1000 live births over 40 years time span from 1940-1980 11 .A study done in tertiary centre inKathmandu, Nepal showed the incidence of CHD to be 5.8 per 1000 hospitalized patients and a community study showed the prevalence of Rheumatic Heart disease and Congenital Heart Disease combined were 1.2 per 1000 and 1.3 per 1000 in school children 12,13 .The present study showed theratio of 1per 9.7 neonate admitted in the NIMCU.This could beattributed to the neonate having CHD is prone to trivial illnesses and being admitted to hospital as compared to a normal neonate.
The commonest congenital heart disease in our study was ASD (87.1%) which was similar to the observation by Rahman S et.al and Siddique FM 15,16 yet our study did not correlate to the other studies which shows VSD as the commonest congenital heart defect 1,12,14 .
Our study showed signifi cant association of non cardiac anomalies and somatic anomalies in 11(12.9%)cases, among which cleft lip cleft palate,Down's syndrome, polydactyly with syndactyly and renal anomaly were the commonest.Studies done by Hofman, Sah GS et.al and Rahaman S et.al.also showed similar results 13,15,17 .
Maternal diseases like diabetes mellitus, maternal infection, hypertension and drugs could affectthe increase occurrence of CHD in neonates.Our study found that only 3.5% mothers had history of infections during pregnancy and only one mother had history of using antipyretic drugs.
Neonates with CHD are more prone to develop intrauterine foetal distress that could mean frequent LSCS either elective or emergency during delivery but our study showed the frequency of normal delivery higher than the LSCS.

Conclusions
Our observations show, prevalence of CHD was the 102.28 per 1000neonates admitted in NIMCU.ASD was the commonest CHD.Cleft lip and Down's syndrome were the most extra cardiac anomalies associated with CHD and that respiratory distress and cyanosis were the commonest presentation of CHD.

Table 4
shows pattern of risk factors in cases of babies with congenital heart disease.Maternal infection was noticed in 3(3.5%) cases.The commonest mode of delivery was spontaneous (71.8%),Elective LSCS were done in 12(14.1%)and Emergency LSCS were done 8(9.4%).

Table 1 :
Presentation of congenital heart disease on admission

Table 2 :
Types of structural defect in CHD in new-borns (n=85)

Table 4 :
Maternal History and Mode of delivery LSCS= Lower Section Caesarean Section