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Premature closure of the ductus arteriosus
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S. Mittal et al. / International Journal of Gynecology and Obstetrics 114 (2011) 76–88
Premature closure of the ductus arteriosus Miroslav Gregor ⁎, Karel Hodík, Jindřich Tošner Department of Obstetrics and Gynecology, Charles University, Hradec Kralove, Czech Republic
a r t i c l e
i n f o
Article history: Received 12 December 2010 Received in revised form 22 January 2011 Accepted 24 March 2011 Keywords: Metamizole Paracetamol Premature closure of the ductus arteriosus Pulmonary hypertension Ventricular hypertrophy
In August 2009, a 29-year-old woman at 31 weeks of pregnancy presented to the Faculty Hospital, Hradec Kralove, Czech Republic, following a bilious attack. She was treated with painkillers and the symptoms subsided; however, she was rehospitalized a week later with the same symptoms. An ultrasound scan revealed expansion of the intrahepatic bile ducts and choledochus. Endoscopic retrograde cholangiopancreatography was performed and the symptoms gradually subsided. At 34 weeks of pregnancy, the woman was hospitalized again with the same symptoms. Cholecystectomy was indicated and carried out with no complications. On the same day, an ultrasound scan of the fetus revealed anhydramnios, right ventricular hypertrophy, and accelerated blood flow through the ductus arteriosus (DA). Cesarean delivery was performed owing to suspected premature DA closure. The newborn made no respiratory effort and had a heart rate of more than 100 beats per minute. A suction device was used to facilitate breathing. The following day, fetal echocardiography showed right ventricular hypertrophy, interventricular septal hypertrophy, and signs of persistent pulmonary hypertension. Respiratory distress syndrome developed on the first day after delivery. The newborn was treated with supplemental oxygen and parenteral nutrition and given prophylactic antibiotics. Breathing had improved by the fourth day and, on the
twelfth day after delivery, echocardiography showed normal heart anatomy, no right ventricular hypertrophy, an adequate interventricular septum width, and a closed DA. The normalized truncus pulmonalis flow indicated that there was no pulmonary hypertension. The newborn was discharged at 21 days of age in a healthy condition, having been breast fed and gained weight. The DA is a vascular shunt connecting the truncus pulmonalis to the aorta. Prostaglandins maintain its patency; however, nonsteroidal antiinflammatory drugs (NSAIDs) can suppress prostaglandin synthesis, often leading to DA closure [1]. In the present case, the mother had no medical history of NSAID use during pregnancy. Over the course of her treatment from initial hospitalization, she received the non-opioid analgesics paracetamol and metamizole (10 g in total). Neither the incidence nor the prognosis of premature DA closure is known. A MEDLINE search revealed only 14 other cases, the predominant etiology of which was NSAIDs. Right ventricular hypertrophy was the most frequent sign during prenatal ultrasound [2] and approximately one-third of fetuses were stillborn [3]. Among the live newborns, pulmonary hypertension, respiratory distress syndrome, and heart alteration dominated. Standard treatment consisted of supplemental oxygen and supportive care. The majority of these newborns were free from disease within 3 weeks of delivery. Appropriate medication during pregnancy may prevent stillbirth and postnatal complications. Conflict of interest The authors have no conflicts of interest. References [1] Koren G, Florescu A, Costei AM, Boskovic R, Moretti ME. Nonsteroidal antiinflammatory drugs during third trimester and the risk of premature closure of the ductus arteriosus: a meta-analysis. Ann Pharmacother 2006;40(5):824–9. [2] Tumbarello R, Pisu F, Pisano E, Puddu R, Bini RM. Timely detection of premature closure of the ductus arteriosus in a full-term fetus. Important role of fetal echocardiography. Minerva Ginecol 1999;51(5):197–201. [3] Harlass FE, Duff P, Brady K, Read J. Hydrops fetalis and premature closure of the ductus arteriosus: a review. Obstet Gynecol Surv 1989;44(7):541–3.
⁎ Corresponding author at: Faculty Hospital, Sokolska 581, Hradec Kralove, Czech Republic. Tel.: + 420 495 832 816; fax: + 420 495 832 100. E-mail address: [email protected] (M. Gregor).
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.01.017
S. Mittal et al. / International Journal of Gynecology and Obstetrics 114 (2011) 76–88
Premature closure of the ductus arteriosus Miroslav Gregor ⁎, Karel Hodík, Jindřich Tošner Department of Obstetrics and Gynecology, Charles University, Hradec Kralove, Czech Republic
a r t i c l e
i n f o
Article history: Received 12 December 2010 Received in revised form 22 January 2011 Accepted 24 March 2011 Keywords: Metamizole Paracetamol Premature closure of the ductus arteriosus Pulmonary hypertension Ventricular hypertrophy
In August 2009, a 29-year-old woman at 31 weeks of pregnancy presented to the Faculty Hospital, Hradec Kralove, Czech Republic, following a bilious attack. She was treated with painkillers and the symptoms subsided; however, she was rehospitalized a week later with the same symptoms. An ultrasound scan revealed expansion of the intrahepatic bile ducts and choledochus. Endoscopic retrograde cholangiopancreatography was performed and the symptoms gradually subsided. At 34 weeks of pregnancy, the woman was hospitalized again with the same symptoms. Cholecystectomy was indicated and carried out with no complications. On the same day, an ultrasound scan of the fetus revealed anhydramnios, right ventricular hypertrophy, and accelerated blood flow through the ductus arteriosus (DA). Cesarean delivery was performed owing to suspected premature DA closure. The newborn made no respiratory effort and had a heart rate of more than 100 beats per minute. A suction device was used to facilitate breathing. The following day, fetal echocardiography showed right ventricular hypertrophy, interventricular septal hypertrophy, and signs of persistent pulmonary hypertension. Respiratory distress syndrome developed on the first day after delivery. The newborn was treated with supplemental oxygen and parenteral nutrition and given prophylactic antibiotics. Breathing had improved by the fourth day and, on the
twelfth day after delivery, echocardiography showed normal heart anatomy, no right ventricular hypertrophy, an adequate interventricular septum width, and a closed DA. The normalized truncus pulmonalis flow indicated that there was no pulmonary hypertension. The newborn was discharged at 21 days of age in a healthy condition, having been breast fed and gained weight. The DA is a vascular shunt connecting the truncus pulmonalis to the aorta. Prostaglandins maintain its patency; however, nonsteroidal antiinflammatory drugs (NSAIDs) can suppress prostaglandin synthesis, often leading to DA closure [1]. In the present case, the mother had no medical history of NSAID use during pregnancy. Over the course of her treatment from initial hospitalization, she received the non-opioid analgesics paracetamol and metamizole (10 g in total). Neither the incidence nor the prognosis of premature DA closure is known. A MEDLINE search revealed only 14 other cases, the predominant etiology of which was NSAIDs. Right ventricular hypertrophy was the most frequent sign during prenatal ultrasound [2] and approximately one-third of fetuses were stillborn [3]. Among the live newborns, pulmonary hypertension, respiratory distress syndrome, and heart alteration dominated. Standard treatment consisted of supplemental oxygen and supportive care. The majority of these newborns were free from disease within 3 weeks of delivery. Appropriate medication during pregnancy may prevent stillbirth and postnatal complications. Conflict of interest The authors have no conflicts of interest. References [1] Koren G, Florescu A, Costei AM, Boskovic R, Moretti ME. Nonsteroidal antiinflammatory drugs during third trimester and the risk of premature closure of the ductus arteriosus: a meta-analysis. Ann Pharmacother 2006;40(5):824–9. [2] Tumbarello R, Pisu F, Pisano E, Puddu R, Bini RM. Timely detection of premature closure of the ductus arteriosus in a full-term fetus. Important role of fetal echocardiography. Minerva Ginecol 1999;51(5):197–201. [3] Harlass FE, Duff P, Brady K, Read J. Hydrops fetalis and premature closure of the ductus arteriosus: a review. Obstet Gynecol Surv 1989;44(7):541–3.
⁎ Corresponding author at: Faculty Hospital, Sokolska 581, Hradec Kralove, Czech Republic. Tel.: + 420 495 832 816; fax: + 420 495 832 100. E-mail address: [email protected] (M. Gregor).
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.01.017