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Dos Santos CS, Silva PV, Castelo R, Tiago J. Premature closure of ductus arteriosus after a single dose of diclofenac during pregnancy. Drug Ther Bull 2022; 60:170-175. [PMID: 36302541 DOI: 10.1136/dtb.2022.243485rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Constança Soares Dos Santos
- Department of Neonatology A, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal .,Department of Paediatrics, Centro Hospitalar Cova da Beira EPE, Covilha, Portugal
| | - Patricia Vaz Silva
- Department of Paediatric Cardiology, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Rui Castelo
- Department of Neonatology A, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Joaquim Tiago
- Department of Neonatology A, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
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Dos Santos CS, Silva PV, Castelo R, Tiago J. Premature closure of ductus arteriosus after a single dose of diclofenac during pregnancy. BMJ Case Rep 2021; 14:14/6/e243485. [PMID: 34167992 DOI: 10.1136/bcr-2021-243485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
A male term neonate was admitted to the neonatal intensive care unit in the first hours of life with central cyanosis. Echocardiogram showed severe biventricular hypertrophy, markedly right-sided, tricuspid regurgitation, a patent foramen ovale and a closed ductus arteriosus (CDA). The mother recalled being treated with a single dose of intravenous diclofenac for low back pain 2 weeks earlier. The newborn was started on propranolol with symptomatic improvement and was discharged on day 10. At 1-month follow-up, he showed complete resolution of ventricular hypertrophy and suspended propranolol. In the literature, of the 22 cases of CDA after intrauterine exposure to diclofenac, 11 resolved in utero, 3 required ventilatory and inotropic support and 1 evolved to persistent pulmonary hypertension. In this case, a thorough anamnesis was key to identify the probable cause of an otherwise unexplained transient ventricular hypertrophy. This case also alerts to the fetal risks of non-steroidal anti-inflammatory drugs during the third trimester, requiring close monitoring.
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Affiliation(s)
- Constança Soares Dos Santos
- Department of Neonatology A, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal .,Department of Paediatrics, Centro Hospitalar Cova da Beira EPE, Covilha, Portugal
| | - Patricia Vaz Silva
- Department of Paediatric Cardiology, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Rui Castelo
- Department of Neonatology A, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Joaquim Tiago
- Department of Neonatology A, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
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Hauben M, Bai S, Hung E, Lobello K, Tressler C, Zucal VP. Maternal paracetamol intake and fetal ductus arteriosus constriction/closure: comprehensive signal evaluation using the Austin Bradford Hill criteria. Eur J Clin Pharmacol 2021; 77:1019-1028. [PMID: 33410971 DOI: 10.1007/s00228-020-03039-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 11/09/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Acetaminophen (APAP) is available over-the-counter and widely regarded as safe for use in pregnancy. APAP has been used to close a persistently patent ductus arteriosus. Fetal constriction/closure of the ductus arteriosus (FCCDA), of public health interest given the drug's widespread use during pregnancy, is being monitored globally, including by the European Medicines Agency Pharmacovigilance Risk Assessment Committee. Our objective was to share a comprehensive signal evaluation of FCCDA with in utero APAP exposure to determine if the totality of evidence is sufficiently more consistent with one of the following two possibilities: (1) APAP never contributes to FCCDA (null hypothesis or HO) versus (2) APAP may in some cases be at least a contributory cause of in utero DA narrowing (alternative hypothesis or HA) to justify risk communication. METHODS To assess the relative support for HO versus HA, we synthesize and interpret within an Austin Bradford Hill criteria framework a comprehensive, cross-disciplinary set of published information and de novo analysis, including toxicology, epidemiology, clinical pharmacology, and clinical and quantitative pharmacovigilance analysis of spontaneous reports. RESULTS While residual uncertainty remains, the totality of information is more compatible with HA than H0, to the extent that it is reasonably possible that APAP may sometimes be at least a contributory cause of FCCDA. CONCLUSION It is reasonably possible that APAP may sometimes be at least a contributory cause of FCCDA, and this should therefore be communicated to stakeholders. TRIAL REGISTRATION CLINICALTRIALS. GOV REGISTRATION NOT APPLICABLE.
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Affiliation(s)
- Manfred Hauben
- Worldwide Safety and Regulatory, Pfizer Inc., 235 E 42nd St, New York, NY, 10017, USA. .,Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA.
| | - Stephen Bai
- Clinical Pharmacology, Pfizer Inc., 235 E 42nd St, New York, NY, 10017, USA
| | - Eric Hung
- Worldwide Safety and Regulatory, Pfizer Inc., 235 E 42nd St, New York, NY, 10017, USA
| | - Kasia Lobello
- Safety Surveillance and Risk Management, Pfizer Inc., 235 E 42nd St, New York, NY, 10017, USA
| | - Charles Tressler
- Safety Surveillance and Risk Management, Pfizer Inc., 235 E 42nd St, New York, NY, 10017, USA
| | - Vincent P Zucal
- Safety Surveillance and Risk Management, Pfizer Inc., 235 E 42nd St, New York, NY, 10017, USA
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Hutson JR, Lurie A, Eastabrook G, de Vrijer B, Garcia-Bournissen F. Acetaminophen in late pregnancy and potential for in utero closure of the ductus arteriosus-a pharmacokinetic evaluation and critical review of the literature. Am J Obstet Gynecol MFM 2020; 3:100288. [PMID: 33451624 DOI: 10.1016/j.ajogmf.2020.100288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/01/2020] [Indexed: 11/29/2022]
Abstract
Acetaminophen has become a novel treatment option for patent ductus arteriosus closure in premature infants. This raises concerns about whether acetaminophen should be avoided in late pregnancy, similar to nonsteroidal anti-inflammatory drugs, because of the risk of in utero ductus arteriosus closure. This article critically evaluated the literature reporting an association between acetaminophen use and in utero ductus arteriosus closure and provided a comparative pharmacokinetic analysis of fetal acetaminophen exposure in pregnancy vs drug levels in neonates, with the goal of making an expert recommendation regarding its safety. Here, 1 prospective cohort study and 12 case reports and series evaluating the risk of premature ductus arteriosus closure with prenatal acetaminophen use were reported and overall do not suggest causation. Pharmacokinetic studies showed that acetaminophen fetal transplacental exposures are well below the levels shown to close the ductus arteriosus in neonates. Short-term use of acetaminophen in the third trimester of pregnancy poses a negligible risk of premature ductus arteriosus closure and can still be considered safe in the third trimester of pregnancy at recommended doses.
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Affiliation(s)
- Janine R Hutson
- Departments of Obstetrics and Gynaecology, Western University, London, Ontario, Canada.
| | - Antony Lurie
- Microbiology and Immunology, Western University, London, Ontario, Canada
| | - Genevieve Eastabrook
- Departments of Obstetrics and Gynaecology, Western University, London, Ontario, Canada; Division of Maternal, Fetal, and Newborn Health, Children's Health Research Institute, Lawson Health Research Institute, London, Ontario, Canada
| | - Barbra de Vrijer
- Departments of Obstetrics and Gynaecology, Western University, London, Ontario, Canada; Division of Maternal, Fetal, and Newborn Health, Children's Health Research Institute, Lawson Health Research Institute, London, Ontario, Canada
| | - Facundo Garcia-Bournissen
- Paediatrics, Western University, London, Ontario, Canada; Division of Children's Health and Therapeutics, Children's Health Research Institute, Lawson Health Research Institute, London, Ontario, Canada
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Allegaert K, Mian P, Lapillonne A, van den Anker JN. Maternal paracetamol intake and fetal ductus arteriosus constriction or closure: a case series analysis. Br J Clin Pharmacol 2019; 85:245-251. [PMID: 30300944 PMCID: PMC6303200 DOI: 10.1111/bcp.13778] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/05/2018] [Accepted: 09/30/2018] [Indexed: 01/15/2023] Open
Abstract
Recent case reports describe an association between maternal paracetamol intake and fetal ductus arteriosus constriction or closure. To put these cases into perspective and explore causality, a structured literature search was conducted. The World Health Organization Uppsala Monitoring Centre (WHO-UMC) causality tool was applied to the cases retrieved. The search resulted in 12 papers with 25 case descriptions, of which one case was classified as unlikely, nine as possible, 11 as probable and four as certain. Consequently, we concluded that a causal relationship between maternal paracetamol intake and fetal ductus arteriosus constriction or closure is likely. These findings suggest that pharmacovigilance studies on paracetamol safety during pregnancy are warranted to quantify the event and put the current findings into clinical perspective. Although analgesia during pregnancy and during the peripartum period is of obvious relevance, alternative analgesics such as opioids or other nonsteroidal anti-inflammatory drugs also have side effects.
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Affiliation(s)
- Karel Allegaert
- Intensive Care and Department of Pediatric SurgeryErasmus MC–Sophia Children's HospitalRotterdamthe Netherlands
- Department of Pediatrics, Division of NeonatologyErasmus MC–Sophia Children's HospitalRotterdamthe Netherlands
- Department of Development and Regeneration KU LeuvenLeuvenBelgium
| | - Paola Mian
- Intensive Care and Department of Pediatric SurgeryErasmus MC–Sophia Children's HospitalRotterdamthe Netherlands
| | - Alexandre Lapillonne
- Department of NeonatologyHôpital Universitaire Necker Enfants Malades, Assistance Publique‐Hôpitaux de ParisParisFrance
- Paris Descartes UniversityParisFrance
| | - John N. van den Anker
- Intensive Care and Department of Pediatric SurgeryErasmus MC–Sophia Children's HospitalRotterdamthe Netherlands
- Division of Pediatric Pharmacology and PharmacometricsUniversity Children's Hospital BaselBasel, Switzerland
- Division of Clinical PharmacologyChildren's National Health SystemWashingtonDCUSA
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Genovese F, Marilli I, Benintende G, Privitera A, Gulino FA, Iozza I, Cimino C, Palumbo MA. Diagnosis and management of fetal ductus arteriosus constriction-closure. J Neonatal Perinatal Med 2015; 8:324352M572245181. [PMID: 25758002 DOI: 10.3233/npm-15814031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Pathognomonic features of in utero premature restriction/closure of the ductus arteriosus (DA) are increased right ventricular afterload, impaired right ventricular function, and consequently tricuspid regurgitation and right heart dilation. The most common reason for constriction-closure of DA is maternal administration of non-steroidal anti-inflammatory drugs (NSAIDs) during the 3rd trimester of gestation. The idiopathic form is a rare event and, maybe, an underestimated abnormality that, if it is not promptly recognized, may result in severe fetal-neonatal compromise. We describe a case of a 38-year-old woman presenting at 34+0 weeks of gestation with a normally grown male fetus whose fetal echocardiography had shown right ventricular hypertrophy, a tortuous S-shaped DA and a significant pulmonary hyperflow. All signs were consistent of an idiopathic severe constriction of DA with a significant fetal cardiac involvement. The patient was admitted to a tertiary care center equipped with Neonatal Intensive Care Unit (NICU), and delivered by cesarean section at 34+4 weeks with a good maternal and neonatal outcome. Based on our experience and a review of the Literature we propose a management algorithm to use when dealing with preterm or early term pregnancy complicated by this fetal hemodynamic malfunction.
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Affiliation(s)
- F Genovese
- Institute of Obstetric and Gynecologic Pathology, Department of Surgery, Division of Obstetrics and Gynecology, S. Bambino Hospital, University of Catania, Catania, Italy
| | - I Marilli
- Institute of Obstetric and Gynecologic Pathology, Department of Surgery, Division of Obstetrics and Gynecology, S. Bambino Hospital, University of Catania, Catania, Italy
| | - G Benintende
- Complex Operative Unit of Prenatal Diagnosis and Medical Genetics, University Hospital Vittorio Emanuele, Catania, Italy
| | - A Privitera
- Department of Paediatric Cardiology, S. Bambino Hospital, University of Catania, Catania, Italy
| | - F A Gulino
- Institute of Obstetric and Gynecologic Pathology, Department of Surgery, Division of Obstetrics and Gynecology, S. Bambino Hospital, University of Catania, Catania, Italy
| | - I Iozza
- Institute of Obstetric and Gynecologic Pathology, Department of Surgery, Division of Obstetrics and Gynecology, S. Bambino Hospital, University of Catania, Catania, Italy
| | - C Cimino
- Department of Pediatrics, University of Catania, Catania, Italy
| | - M A Palumbo
- Institute of Obstetric and Gynecologic Pathology, Department of Surgery, Division of Obstetrics and Gynecology, S. Bambino Hospital, University of Catania, Catania, Italy
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Lopes LM, Carrilho MC, Francisco RPV, Lopes MAB, Krebs VLJ, Zugaib M. Fetal ductus arteriosus constriction and closure: analysis of the causes and perinatal outcome related to 45 consecutive cases. J Matern Fetal Neonatal Med 2015; 29:638-45. [DOI: 10.3109/14767058.2015.1015413] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lombardi M, Tagliente MR, Pirolo T, Massari E, Vairo U. Transient and anatomic isolated right-ventricular hypoplasia. J Cardiovasc Med (Hagerstown) 2014; 17 Suppl 2:e257-e263. [PMID: 27042895 DOI: 10.2459/jcm.0b013e328364dc3b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Maristella Lombardi
- Department of Pediatric Cardiology, Ospedale Pediatrico Giovanni XXIII, Bari, Italy
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Choi EY, Li M, Choi CW, Park KH, Choi JY. A case of progressive ductal constriction in a fetus. Korean Circ J 2013; 43:774-81. [PMID: 24363755 PMCID: PMC3866319 DOI: 10.4070/kcj.2013.43.11.774] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Revised: 07/05/2013] [Accepted: 07/17/2013] [Indexed: 11/11/2022] Open
Abstract
The ductus arteriosus is a normal and essential structure in fetal circulation. Since the introduction of fetal echocardiography, there have been reports of ductal constriction, many of which were related to maternal use of some medications. However, there have been some reports of idiopathic ductal constriction, which usually present in later gestation. Recently we experienced a case, which initially showed an S-shaped ductus with mild narrowing at 23 weeks and 27 weeks gestation and developed severe ductal constriction at 33 weeks. Soon after birth, ductus was searched for but no ductus was found in 2-D and color images. The neonate required mechanical ventilation with supplemental oxygen for 3 days. All echocardiographic abnormalities were normalized in 7 months. We report progressive ductal constriction in an S-shaped ductus and emphasize the importance of continuous follow up extending to the third trimester and even immediately after birth.
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Affiliation(s)
- Eun Young Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Meihua Li
- Department of Pediatric Cardiology, Harbin Children's Hospital, Harbin, China
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyo Hoon Park
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Yun Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
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Kaulitz R, Haen S, Sieverding L, Ziemer G. Intrauterine rupture of anterior tricuspid valve papillary muscle: Tricuspid valve chordae replacement on the first day of life. J Thorac Cardiovasc Surg 2012; 143:241-3. [DOI: 10.1016/j.jtcvs.2011.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 06/14/2011] [Accepted: 07/14/2011] [Indexed: 11/28/2022]
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Gewillig M, Brown SC, De Catte L, Debeer A, Eyskens B, Cossey V, Van Schoubroeck D, Van Hole C, Devlieger R. Premature foetal closure of the arterial duct: clinical presentations and outcome. Eur Heart J 2009; 30:1530-6. [DOI: 10.1093/eurheartj/ehp128] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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