Vol 6 No 3 full text fix.indd
Althea Medical Journal. 2019;6(3)
115
Congenital Heart Disease Characteristics in Low Birth Weight Infants
at Dr. Hasan Sadikin General Hospital in 2010–2014
Villia Damayantie,1 Sri Endah Rahayuningsih,2 Irvan Afriandi3
1Faculty of Medicine Universitas Padjadjaran, Indonesia, 2Department of Child Health Faculty
of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, Indonesia,
3Department of Public Health Faculty of Medicine Universitas Padjadjaran, Indonesia
Correspondence: Villia Damayantie, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang
Km.21, Jatinangor, Sumedang, Indonesia, Email: villia.damayantie@yahoo.co.id
Introduction
Congenital heart disease (CHD) accounts
for nearly one-third of all major congenital
anomaly and is known as one of the main
causes of death in the first year of life.
Congenital heart disease is defined as an
anomaly in the macroscopic structure of the
heart or the large blood vessel, which can cause
functional disorders.1 Most causes of CHD are
multi-factorial, which are a combination of
genetic predisposition and environmental
stimuli. Some CHD cases are associated with
chromosomal abnormality.2 The other risk
factors include maternal comorbidities, family
history of CHD, being born as the first child,
medications taken during the pregnancy, and
the age of the mother.3 The incidence of CHD
worldwide varies from year to year, with the
estimation of 8 out of 1,000 (0.8%) live births.
Several studies show that the incidence of
CHD is more common in infants with low
birth weight (LBW) than in the entire neonate
population.4–6 Low birth weight is defined
as birth weight less than 2,500 grams. The
incidence of LBW infants is about 20.6 million
and it accounted for 15.5% of all births globally
and 95.6% has occurred in the developing
countries. In Indonesia7, the prevalence of
LBW infants is 10.2%, and 902 cases are found
in Bandung, West Java.
A study conducted in Korea5 shows that the
highest incidence of CHD has been found in
a subgroup of infants born with 1,000–2,500
grams of birth weight, which is 9.3%of the
entire population. The most common type
of lesions is ventricular septal defect (VSD),
which comprises 48.9% of the total 7,245
AMJ. 2019;6(3):115–22
Abstract
Background: Congenital heart disease (CHD) is a multifactorial disease defined as an anomaly in
the macroscopic structure of the heart that may cause functional disorders. The incidence of CHD is
reported higher in infants with low birth weight (LBW) than the entire population of neonates. This
study aimed to describe the characteristics of CHD in infants born with LBW.
Methods: This was a retrospective descriptive study with a cross-sectional design, performed in
October–November 2015. Data were obtained from medical records of inpatients infants at Dr.
Hasan Sadikin General Hospital, Bandung in the period of 2010–2014. The data presented were the
characteristics of CHD in LBW infants.
Results: Of 364 LBW infants treated in the hospital within 5 years period, 21 infants (14 girls and 7
boys) were diagnosed as CHD, with birth weight group predominantly (n18; 85.7%) in the range of
1,500–2,499 gr. Non-cyanosis CHD was prevalent in 95.2% (n20),and patent ductus arteriosus (PDA)
was found in 76.1% (n16). Comorbid conditions mostly found in this study were preterm birth (n17),
sepsis (n10), and neonatal hyperbilirubinemia (n9).
Conclusions: The most common type of CHD in low birth weight infants in Dr. Hasan Sadikin General
Hospital is Patent Ductus Arteriosus. The presence of congenital heart disease should be considered in
low birth weight infants, thus it is essential to perform screening for early recognition.
Keywords: Congenital heart disease, infants, low birth weight
Althea Medical Journal. 2019;6(3)
116 AMJ September 2019
cases.6 Lesions of CHD can lead to LBW due
to the presence of hemodynamic disorders.
Moreover, CHD in LBW infants may present
with other comorbid conditions and could
increase infant morbidity and mortality.8–13
In Indonesia, there are not many studies
describing CHD in LBW infants, especially in
West Java. This study aimed to describe the
characteristics of CHD in infants born with
LBW.
Methods
A descriptive method with cross-sectional
research design was conducted. Data
collections were obtained from medical
records of hospitalized patients with CHD in
infants born with LBW within 5-year, from
January 2010 until December 2014. Data were
taken from October to November 2015 from the
Medical Records Installation of the inpatients
of the Perinatology Room at Dr. Hasan Sadikin
General Hospital. The study was approved by
the Health Research Ethics Committee of Dr.
Hasan Sadikin General Hospital.
All data of newborn infants aged up to
28 days with LBW who were admitted in
the Perinatology Room at Dr. Hasan Sadikin
General Hospital were collected (n 364).
The inclusion criteria of this study were
complete medical records of LBW infants aged
0–28 days with CHD diagnosed through an
echocardiography examination.
The selected data were categorized into four
groups consisting of the infant characteristics,
mother characteristics, type of CHD lesion
that was classified into cyanosis and non-
cyanosis types of lesion, and comorbidity. In
the infant characteristic category, the selected
data included gender, birth weight, birthplace,
and the 10-point Apgar score. Data on birth
weight was categorized based on birth weight
group of 1,500–2,499 grams, 1,000–1,499
grams, and <1,000 grams. The Apgar score
was divided into three categories, with 7–10
points categorized as excellent condition,
4–6 points as moderately depressed, and
1–3 points as severely depressed.12 In the
mother characteristic category, the selected
data included mother parity, gestational age,
No CHD diagnosis
n=278
CHD diagnosis
n=86
Study population: Medical Records of LBW infants
n=364
No Echocardiography
n=43
Incomplete
Medical Records
n=22
Complete Medical records and
Echocardiography
n=21
Suspects of CHD
Incompleteresult:
only echocardiography
n=1
Incomplete result:
chest X-Ray and
echocardiography,
NO electrocardiography
n=11
Completed result:
chest X-Ray,
electrocardiography, and
echocardiography
n=9
Figure 1 Flowchart Data Collection
Althea Medical Journal. 2019;6(3)
117Villia Damayantie et al.: Congenital Heart Disease Characteristics in Low Birth Weight Infants at Dr. Hasan
Sadikin General Hospital in 2010–2014
frequency of antenatal care (ANC) visit, and
medication history during the pregnancy.
Gestational age was divided into pre-term for
<37 weeks gestational age, a term for 37–42
weeks gestational age, and post-term for >42
weeks gestational age. The frequency of ANC
visitwas divided into less than four times, and
four times or more. In the type of CHD lesion
category, the selected data included the type
of lesion, both the cyanosis and non-cyanosis,
and the presence of supporting exam results
including chest X-ray, electrocardiography
(ECG), and echocardiography. In the
comorbidity condition category, the selected
data included other diseases and other
congenital abnormalities in the infants. The
data were analyzed and presented in tables.
Results
There were 21 data obtained from 364 infants
with LBW. Other 343 medical record data
were excluded consecutively, 278 of them did
not contain any CHD diagnosis, 22 of them
were lost, and 43 of them were excluded
because CHD was not confirmed through the
echocardiography examination step. Data
were included, only if CHD was confirmed by
echocardiography (Figure 1).
In this study, 11 out of 21 samples were
born in the hospital and the rest of 10 samples
were born assisted by midwives. There were
14 female infants and 7 male infants (Table 1).
In the birth weight group, the highest
frequency was in those born with a birth
weight of 1,500–2,499 grams and there was no
infant born with a birth weight <1,000 grams
found in this study.
The results of 1-Minute Apgar scores in
this study were mostly found in the excellent
category, however, there were 11 samples
whose results of 1-minute Apgar scores were
not recorded in their medical records (Table
2). The results of 5-Minute Apgarscores in
this study were mostly found in the excellent
category, yet, there were 12 samples whose
results of 5-minute Apgar scores were not
recorded in their medical records. The results
in 10-Minute Apgar scores in this study were
mostly found in the excellent category(three
samples). Meanwhile, there were 17 samples
whose results of 10-minute Apgar scores were
not recorded in their medical records.
As shown in Table 3, the highest frequency
of parity status was multiparity mothers.
Most of the mothers delivered the baby in the
gestational age of fewer than 37 weeks and
most of them had ANC visit frequency less than
4 times. Unfortunately, only 6 of 21 mothers
took vitamins such as iron and calcium tablets
given by midwives or doctors at each ANC
visit. Interestingly, only one mother received
TT immunization during pregnancy of which
there were 6 mothers with the first pregnancy.
Table 2 Distribution of Apgar Scoresof Infants with Low Birth Weight (n=21)
Apgar Scores
1-Minute 5-Minute 10-Minute
Total (n) Total (n) Total (n)
Severely depressed 2 1 -
Moderately depressed 2 2 1
Excellent condition 6 6 3
Without Information 11 12 17
Notes: 10-points APGAR score designated as Severely depressed: 1–3 points; Moderately depressed: 4–6 points;
Excellent condition: 7–10 points
Table 1 Distribution of Birth Weight Groups-for-Gender of Infants
Birth Weight Groups
Gender Total
(n)Male Female
1,500–2,499 grams 6 12 18
1,000–1,499 grams 1 2 3
<1,000 grams - - -
Total 7 14 21
Althea Medical Journal. 2019;6(3)
118 AMJ September 2019
However, 12 out of 21 samples did not record
the history of medication during pregnancy in
their medical records.
The highest frequency of CHD lesion in this
study was non-cyanosis with patent ductus
arteriosus (PDA) and found in 16 out of 21
samples (Table 4). Interestingly five out of 21
infants had more than one lesion whichwas
PDA with a patent foramen ovale (PFO).
The number of infants who were born with
CHD lesion might be comorbid by the presence
of other congenital abnormalities, such as
Down syndrome and Labiognatapalatoschizis.
However, most of them had no other
Table 3 The distribution of Characteristic from Maternal Factors
Maternal Factors Total (n)
Parity
Primiparous 6
Multiparous 14
Grandmultiparous 1
Gestational Age
Preterm birth 17
Aterm birth 4
Post-term birth -
Frequency of Antenatal Care Visits
<4 times 12
≥4 times 9
Medication History During Pregnancy
Herbal Medicine -
Supplement 6
Drugs for hypertension mother 2
TT Immunization 1
Without Information 12
Note: Preterm birth: <37 weeks; Aterm birth: 37–42 weeks; Post-term birth: >42 weeks. TT, tetanus toxoid
Table 4 The Distribution of Type Lesions of Congenital Heart Disease(CHD)
Type of Lesions Amount (n)
Cyanosis CHD
TGA 1
Non-CyanosisCHD
ASD 2
VSD 3
PDA>72 hours 16
Multiple Lesions
ASD andVSD 1
PDA andPFO 5
VSD andPFO 1
Note: ASD: Atrial Septal Defect; PDA: Patent DuctusArteriosus; PFO: Patent Foramen Ovale; TGA: Transposition of Great
Arteries; VSD: Ventricular Septal Defect
Althea Medical Journal. 2019;6(3)
119Villia Damayantie et al.: Congenital Heart Disease Characteristics in Low Birth Weight Infants at Dr. Hasan
Sadikin General Hospital in 2010–2014
Table 5 Distribution of Comorbidity
Comorbidity Total (n)
Other Congenital Abnormalities
Down Syndrome 2
Congenital Hypothyroid 1
Hirschsprung Disease 1
Labiognatapalatoschizis 2
Without any congenital disorder 16
Other Diseases/Conditions
Preterm Infants 17
Sepsis 10
Neonatal Hyperbilirubinemia 9
Omphalitis 5
Pneumonia 5
Anemia 4
Respiratory Distress Syndrome 4
Thrombocytopenia 4
Hypoglycemia 3
Small Gestational Age 3
Apneu of Prematurity 2
Asphyxia 2
G6PD Deficiency 2
Dehydration 2
Hypernatremia 2
Hyponatremia 2
Bacterial Infection 2
TORCH Infection 2
Feeding Problem 2
Bilirubin Encephalopathy 1
Hyperkalemia 1
Hypercalcemia 1
IUGR 1
Conjunctivitis 1
Prolonged aPTT 1
Phlebitis Dorsum Magnus 1
Transient Tachypnea of Newborn 1
Note: G6PD deficiency: Glucose-6-phosphate dehydrogenase deficiency; TORCH infection: Toxoplasmosis, Other,
Rubella, Cytomegalovirus, and Herpes infection; IUGR: Intrauterine Growth Restriction; Prolonged aPTT: Prolonged
activated-Partial Thromboplastin Time
Althea Medical Journal. 2019;6(3)
120 AMJ September 2019
accompanied congenital abnormalities. The
most comorbid condition found in this study
was preterm birth (17 out of 21) followed by
sepsis and neonatal hyperbilirubinemia (Table
5).
Discussion
This study describes an overview of therapeutic
Congenital heart disease is generally caused
by a fetal development disorder or structural
failure in the embryogenesis process.14 The
incidence of CHD worldwide varies from year
to year, with the estimation of 8 out of 1,000
(0.8%) live births.1,14 Congenital heart disease
incidence in infants with LBW is found at a
higher rate. Several studies have reported that
infants with CHD are at higher risk of having
small gestational age (SGA) condition which
is closely related to LBW.4,5 This study found
that 21 out of 364 LBW infants were born with
CHD resulting in an incidence of 5.7% (Figure
1). The study result showed that the CHD
cases with LBW were predominantly in female
infants (Table 1). This is consistent with a
study, describing that the frequency of female
infants is found higher than the male infants.6
Low birth weight defined as an infant
with birth weightless than 2,500 grams.15 In
Indonesia, according to the result of Basic
Health Research (Riset Kesehatan Dasar,
RISKESDAS) in 2013, the prevalence of infants
born with LBW is 10.2%.7 On the other hand,
902 infants are born with LBW in Bandung,
West Java, while there are 438 infants born
with LBW in Bandung Regency.16 Low birth
weight is divided into three categories, referred
as LBW for a birth weight ranging from 1,500–
2,499 grams, very low birth weight (VLBW) for
birth weight ranging from 1,000–1,499 grams,
and extremely low birth weight (ELBW) for
birth weight ranging from less than 1,000
grams. However, in this study, all categories
were generally referred to as LBW. The study
showed that CHD infants were mostly found in
the birth weight range of 1,500–2,499 grams,
which were 18 out of 21 samples (Table 1).
A study conducted in Korea5 showed that
when patients were being categorized based
on their birth weight (≥2,500 grams, 1,000–
2,500 grams, and <1,000 grams), the highest
CHD incidence was found in the birth weight
subgroup of 1,000–2,500 grams, comprising
of 9.3% (p<0.001), compared to the other two
groups, thus the incidenceswere found higher
in the LBW group than non-LBW.5
The birth of an infant with LBW occurs
in those who are preterm birth or having
intrauterine growth restriction.15 This concept
is parallel to thestudy result that showedmost
of the infants were born at <37 weeks of
gestational age (Table 3). Moreover, the result
showed someinfants had intrauterine growth
restriction (IUGR) as a comorbid condition
(Table 5).
Several other factors affecting LBW include
maternal factors, infant factors, and socio-
economic conditions. The relationship of
mother characteristics and the incidence of
LBW indicated significant relationships among
pregnancy check-up of ANC, the number of
parity, the interval between pregnancies of
<12 months, mother weight gain, and bad
obstetric history.17 Our study showed that the
highest frequency of CHD infants with LBW
was found in mothers who had more than one
delivery, or multiparity (Table 3). Although
other studies stated that the risk of infants
born with LBW is threefold higher in those
of primiparity than multiparity mother.17 The
result of ANC visits in this study was similar
compared to other studies, that mothers with
less frequency of ANC visits have almost six
times higher risk of having an LBW baby in
comparison to mothers who have 5 or more
ANC visits. The frequency of ANC visits is
essential healthcare maintenance for pregnant
women. During ANC nutritional status of the
mother will be assessed, such a condition can
also affect fetal nutrition. Early detection of
congenital anomaly can be assessed through
fetal monitoring during ANC visits. Thus, the
less frequent mother received ANC, the risk of
having infants LBW and/or any other anomaly
condition will be higher.17
Since CHD is a multifactorial disease,
a combination of genetic predisposition
and exogenous factors such as maternal,
gestational, and environmental conditions
need to be considered. Some of CHD cases
are also associated with chromosome
abnormality, especially trisomy 21, 13, 18, and
Turner syndrome.2 Several studies mentioned
that the most common congenital disorder is
Down Syndrome,3,18 in line with the result of
this study that the most common comorbid
congenital disorder is Down Syndrome and
Labiognatapalatoschizis (Table 5). However,
most of them are not accompanied by other
congenital disorder.
Other risk factors include maternal
comorbidities, family history of the disease,
being born as the first child, medication
taken during pregnancy, age of the mother,
and gender of the infant.3 In this study, two
mothers took hypertension and heart disease
Althea Medical Journal. 2019;6(3)
121
medication during pregnancy (Table 3). A
study showed that hypertension drugs may
increase the risk of preterm birth, SGA, and
infants suffering from an abnormality of
cardiovascular system.19
Congenital heart disease is generally
divided into two classes, the cyanosis, and non-
cyanosis. The cyanosis is characterized by the
presence of central cyanosis due to the right-
to-left shunts. Some of the lesions are tetralogy
of Fallot, transposition of the great arteries
(TGA), and tricuspid atresia. While non-
cyanosis CHD is characterized by the presence
of cardiac septum defect and followed by left-
to-right shunts, including VSD, ASD, or patency
of some blood vessels that are supposed to be
closed as in PDA. Furthermore, non-cyanosis
CHD can also be found in an obstruction of
the outflow tract of the ventricle like aortic
valve stenosis, pulmonary valve stenosis, and
coarctation of the aorta.2,20 Non-cyanosis was
the most frequent type of lesion found in this
study, in a ratio of 20:1 with the cyanosis one
(Table 4).The most common lesion found
in this study was PDA, 16 out of 21 samples,
while TGA had the lowest frequency because it
was only found in one out of 21 samples. Some
of the previous studies usually excluded the
PDA lesion due to prematurity which appears
during <72 hours in infants who are born
preterm. Meanwhile, in this study, samples
with PDA were diagnosed in >72 hours in spite
of their prematurity.
The diagnosis of congenital heart disease
is based on anamnesis to see the risk factors
and disease history, physical examination to
determine the presence/absence of cyanosis
and examination of heart sound and murmurs,
and other supporting examinations. Basic
supporting examinations for CHD is chest X-ray
to see if there are any enlargement of the heart
and vascular marking, electrocardiography
(ECG) to see if cardiomegaly or any deviation is
found in patients, and routine laboratory tests.
Further supporting examinations are also
conducted in the form of echocardiography
and cardiac catheterization to confirm a
CHD diagnosis. The combination of both
examinations allow diagnosis for approaching
one hundred percent of accuracy.2
Congenital heart disease lesion results in
infants born with LBW due to hemodynamic
disorders. This hemodynamic disorder can lead
to increased metabolism, which consequently
increases the energy consumption. A CHD
infant cannot fulfill this increased energy
consumption because he/she suffers from
calorie intake impairment. This impairment
is presumably caused by the inability of the
body to use nutrition for metabolism due to
malabsorption and asphyxia. Eventually, a
manifestation will appear in the form of LBW
and other comorbid conditions that contributed
to the worsening state of the infants (Table 5).8
Many infants require corrective or palliative
surgery and hospitalization during the first
year of life. Results of the surgery depend
on the complexity of the lesions and infant
characteristics such as lung development,
prematurity, and body weight.4,13 Compared to
infants born with normal weight, LBW infants
with CHD who have undergone surgery are at
higher risk of mortality and morbidity.11,13
Factors associated with CHD infant
morbidity include LBW, prematurity and
other conditions such as comorbid diseases.
This study showed that the most common
comorbid condition was preterm birth,
followed by neonate sepsis. Moreover,
there were metabolic disorders found, such
as neonate hyperbilirubinemia, followed
by pneumonia, umbilical cord infection,
respiratory distress syndrome (RDS) and
abnormality in blood systems such as anemia
and thrombocytopenia.
The factors affecting mortality include a
birth weight that is less than 1,500 grams, the
current low body weight before surgery, and
the Apgar score. Generally, the Apgar score
is used to determine the level of asphyxia or
how much apatient can lose the oxygen level
in his/her circulation. These factors may
determine the prognosis of a baby born with
LBW and diagnosed CHD.12 The Apgar score in
this study mostly belonged in a good category
(Table 2). However, some Apgar score data
were not recorded in the medical records, as
the reasons were stated in the result part. As
the Apgar score worsens, so did the infant
prognosis, and it was marked by the increase
in the morbidity and even mortality.
This study has several limitations; the
study was carried out as a small regional study
which may not reflect the actual number of the
population. Therefore, research with a large
number of samples is recommended. There
were also missing and incomplete medical
records data. Due to this, data collection from
inpatients that were born or admitted should
be more organized. Some Apgar scores were
not recorded in the medical records due to two
reasons; first, there were 10 deliveries handled
by midwives and they did not perform the
Apgar test post-delivery to the infants. Second,
Villia Damayantie et al.: Congenital Heart Disease Characteristics in Low Birth Weight Infants at Dr. Hasan
Sadikin General Hospital in 2010–2014
Althea Medical Journal. 2019;6(3)
122 AMJ September 2019
several samples already had excellent1-Minute
Apgar score, thus, no further assessment was
needed.
In conclusion, the most common type of
CHD in low birth weight infants in Dr. Hasan
Sadikin General Hospital is Patent Ductus
Arteriosus. The presence of congenital heart
disease should be considered in low birth
weight infants; thus, screening is essential for
early recognition.
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