Burden of Illness
Due to its high rate of mortality and morbidity, prematurity is by far the most important issue in modern perinatal medicine. Patent ductus arteriosus (PDA) is very common among very low birth weight infants (VLBW), the delay in closure of the ductus is inversely related to gestational age varying from 20% in premature infants greater than 32 weeks up to 60% in extreme low birth weight infants (ELBW < 1000 g) [1, 2]. PDA results in a significant left to right shunt with an increase in left ventricular output. Although it usually closes spontaneously by 5 days of age in most infants > 30 weeks' gestation, it remains patent by 5 days of age in more than two thirds of infants < 30 weeks .
Although controversial, observational data confirmed an association of PDA with the subsequent development of bronchopulmonary dysplasia (BPD) in premature infants [4, 5]. It has also been demonstrated that large left to right shunting through the ductus results in a diastolic steal of blood flow to vital organs i.e. brain, kidneys, and intestines . However, recent observational data failed to show an association of PDA with necrotizing enterocolitis (NEC) . Failure of the ductal constriction has been shown to be associated with low superior venacaval flow (SVC) and subsequent occurrence of late intraventricular hemorrhage (IVH) . Lastly, large left to right ductal shunting is associated with a significant increase in pulmonary blood flow and serious pulmonary hemorrhage [9, 10].
Indomethacin prophylaxis vs. treatment for symptomatic PDA; the clinical dilemma
There is now a substantial body of literature available to evaluate the role of indomethacin prophylaxis in the management of the premature infant. Indomethacin prophylaxis reduces the incidence of symptomatic PDA by 55%, severe grade III and IV IVH by 35%, and the need for surgical PDA ligation by 50% [11, 12]. In addition a recent ancillary analysis on the database of the trial of indomethacin prophylaxis in the preterm infants (TIPP trial), showed a significant reduction of serious clinically significant pulmonary hemorrhage during the first week of life .
However, this significant reduction in symptomatic PDA, severe IVH, and serious pulmonary hemorrhage did not translate in reduction of mortality, BPD, and more importantly the rates of long term neurosensory outcome.
As a result of the data presented above, clinicians caring for premature infants are left uncertain of what would be the most sensible approach to the use of indomethacin prophylaxis in the preterm. Some clinicians would justify its use based on the reduction of important intermediate morbidities. On the other hand, others would refrain employing a prophylactic strategy bearing in mind the lack of long term improvement in mortality rate and neurosensory outcome .
Patient decision aids can improve the quality of decision-making, reduce decisional conflict and help patients become involved in decision making by providing information about the options and outcomes and by clarifying personal values. They are designed to complement, rather than replace, counseling from a health practitioner. The medical literature has observed an increasing number and utilization of decision aids in patients management in various fields of medicine [15–17].