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Pulmonary hemorrhage in extremely low birth weight infants: Significance of the size of left to right shunting through a valve incompetent patent foramen ovale



Pulmonary hemorrhage is a rare but severe complication of extremely low birth weight (ELBW) infants. The association of hemodynamically significant patent ductus arteriosus (hsPDA) and the diameter of the foramen ovale (FO) with pulmonary hemorrhage has not been reported.

Study Design

Case control study of ELBW infants with and without pulmonary hemorrhage. Each ELBW infant with an echocardiogram within 48 h of pulmonary hemorrhage was analyzed.


16 infants with pulmonary hemorrhage were matched with 32 controls by birth weight and gestational age. Echocardiogram showed hsPDA in all infants and those with pulmonary hemorrhage had significantly smaller patent FO [PFO] (1 vs 2.4 mm, p < 0.01) (OR 0.007; 95% CI 0.00007, 0.67 p = 0.03). Incidence of pulmonary hemorrhage was 8.9%.


ELBW infants with hsPDA who experienced pulmonary hemorrhage had a significantly restricted or closed FO. Evaluation of FO should be considered with serial echocardiograms when evaluating for hsPDA.

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Fig. 1
Fig. 2
Fig. 3: Echocardiogram examples of PFO for control patient and Pulmonary hemorrhage patient.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article.


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We would like to thank the neonatologists, neonatal fellows, and staff at LAC + USC Medical Center NICU for their dedication and hard work in taking care of sick infants. There was no funding for this study.

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Authors and Affiliations



JK contributed to the collection of baseline demographics, implementation, and analysis of the measurements as well as drafting the manuscript. ME, RDCS contributed to the echocardiogram analysis. MU helped obtain echocardiograms and contributed support in research design. BS contributed to the original idea of the manuscript, performed the echocardiographic measurements, and supervised the draft of the manuscript. LB contributed to gathering demographic data from our NICU database. RC contributed to the drafting and statistical analysis of the manuscript. RR contributed to editing and revising the manuscript.

Corresponding author

Correspondence to Jaclyn M. Kappico.

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The authors declare no competing interests.

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Kappico, J.M., Cayabyab, R., Ebrahimi, M. et al. Pulmonary hemorrhage in extremely low birth weight infants: Significance of the size of left to right shunting through a valve incompetent patent foramen ovale. J Perinatol 42, 1233–1237 (2022).

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