Premature Closure of the Ductus Arteriosus and Veno-Arterial Extracorporeal Membrane Oxygenation in Critically Ill Neonates: A 10-Year Single-Center Retrospective Study

To describe critically ill neonates with premature closure of the ductus arteriosus (DA) and assess the frequency as well as predictive factors for extracorporeal membrane oxygenation (ECMO) support in the latter. This was a monocentric retrospective observational study conducted in the NICU of a French academic medical center between 01/01/2013 and 01/01/2023. All neonates diagnosed with premature closure of the DA were included. Exclusion criteria were associated congenital heart disease amenable to urgent surgery or contraindication for ECMO. Eleven neonates with complete premature closure of the DA were included. Births were full-term with a weight of 3.60 kg [3.16-3.89]. Only one case (9%) was diagnosed antenatally. Premature closure of the DA was idiopathic in seven neonates (64%) and associated to maternal exposure to non-steroidal anti-inflammatory drugs (NSAIDs) in three (27%). All newborns had pulmonary hypertension (PH) and right ventricular hypertrophy. Three neonates (27%) were supported on veno-arterial ECMO and appeared to have more pathological adaptation to extra-uterine life, greater need for vasopressor and/or inotropic support, and higher frequency of bi-ventricular failure (100%) or morphological anomaly of the tricuspid valve (67%). No patient died but more than half had non-cardiological sequelae. Veno-arterial ECMO support is not uncommon in critically ill neonates with premature DA closure and appeared to be associated with more pathological adaptation to extra-uterine life, greater need for vasoactive-inotropic support and higher frequency of bi-ventricular failure or morphological anomaly of the tricuspid valve. These parameters can help clinicians to identify neonates likely to require such an assistance.

Engineered tissue geometry and Plakophilin-2 regulate electrophysiology of human iPSC-derived cardiomyocytes

Engineered heart tissues have been created to study cardiac biology and disease in a setting that more closely mimics in vivo heart muscle than 2D monolayer culture. Previously published studies suggest that geometrically anisotropic micro-environments are crucial for inducing "in vivo like" physiology from immature cardiomyocytes. We hypothesized that the degree of cardiomyocyte alignment and prestress within engineered tissues is regulated by tissue geometry and, subsequently, drives electrophysiological development. Thus, we studied the effects of tissue geometry on electrophysiology of micro-heart muscle arrays (μHM) engineered from human induced pluripotent stem cells (iPSCs). Elongated tissue geometries elicited cardiomyocyte shape and electrophysiology changes led to adaptations that yielded increased calcium intake during each contraction cycle. Strikingly, pharmacologic studies revealed that a threshold of prestress and/or cellular alignment is required for sodium channel function, whereas L-type calcium and rapidly rectifying potassium channels were largely insensitive to these changes. Concurrently, tissue elongation upregulated sodium channel (NaV1.5) and gap junction (Connexin 43, Cx43) protein expression. Based on these observations, we leveraged elongated μHM to study the impact of loss-of-function mutation in Plakophilin 2 (PKP2), a desmosome protein implicated in arrhythmogenic disease. Within μHM, PKP2 knockout cardiomyocytes had cellular morphology similar to what was observed in isogenic controls. However, PKP2-/- tissues exhibited lower conduction velocity and no functional sodium current. PKP2 knockout μHM exhibited geometrically linked upregulation of sodium channel but not Cx43, suggesting that post-translational mechanisms, including a lack of ion channel-gap junction communication, may underlie the lower conduction velocity observed in tissues harboring this genetic defect. Altogether, these observations demonstrate that simple, scalable micro-tissue systems can provide the physiologic stresses necessary to induce electrical remodeling of iPS-CM to enable studies on the electrophysiologic consequences of disease-associated genomic variants.

Percutaneous Modified Blalock-Taussig Shunt Closure in a Patient with Isolated Right Ventricular Hypoplasia

Clinical presentation, course, and treatment for patients with isolated right ventricular (RV) hypoplasia (IRVH) depends on the degree of hypoplasia that is present-this is a spectrum from spontaneous maturation to Fontan circulation over time. An 8-month-old infant presented with IRVH; in the patient, a modified Blalock-Taussig (MBTS) shunt was closed percutaneously after spontaneous RV function recovery. A female newborn was diagnosed with differential cyanosis at birth. The echocardiography showed a hypertrophic RV with a small cavity, a right-left shunt on the atrial septal defect, an almost closed ductus arteriosus (DA), and a small tricuspid valve ring (Z-score-2) with mild regurgitation (pressure gradient 30 mmHg). On the 4th day of life, the patient showed deepened cyanosis and hyperlactatemia was registered. The echocardiography examination revealed a closed DA. Right ventriculography performed on the 5th day of life evidenced the presence of a small hypertrabeculated RV. The pressure in the RV increased. A right-side MBTS was created on the 6th day of life. Further echocardiographic findings indicated a gradual development of the RV and a decrease in RV pressure. MBTS occlusion was performed when the patient was 8 months old. Vital parameters were monitored invasively and noninvasively after the balloon occlusion of MBTS. Percutaneous MBTS occlusion was successfully performed using an Amplatzer vascular plug 2 (AVP2). During the follow-up period, the patient was found to have maintained a normal percutaneous oxyhaemoglobin blood saturation.

Acute resveratrol exposure does not impact hemodynamics of the fetal sheep

Babies born growth restricted are at an increased risk of both poor short-and long-term outcomes. Current interventions to improve fetal growth are ineffective and do not lower the lifetime risk of poor health status. Maternal resveratrol (RSV) treatment increases uterine artery blood flow, fetal oxygenation, and fetal weight. However, studies suggest that diets high in polyphenols such as RSV may impair fetal hemodynamics. We aimed to characterize the effect of RSV on fetal hemodynamics to further assess its safety as an intervention strategy. Pregnant ewes underwent magnetic resonance imaging (MRI) scans to measure blood flow and oxygenation within the fetal circulation using phase contrast-MRI and T2 oximetry. Blood flow and oxygenation measures were performed in a basal state and then repeated while the fetus was exposed to RSV. Fetal blood pressure and heart rate were not different between states. RSV did not impact fetal oxygen delivery (DO2 ) or consumption (VO2 ). Blood flow and oxygen delivery throughout the major vessels of the fetal circulation were not different between basal and RSV states. As such, acute exposure of the fetus to RSV does not directly impact fetal hemodynamics. This strengthens the rationale for the use of RSV as an intervention strategy against fetal growth restriction.

Fetal Ductus Arteriosus Premature Constriction

This study aimed to investigate the connections between the echocardiography indices of fetal ductus arteriosus premature constriction and newborn prognosis by analyzing 22 cases of spontaneous fetal ductus arteriosus premature constriction.An ultrasonic instrument was used to observe prenatal fetal heart state, combine clinical examination data and echocardiographic results after delivery, summarize the ultrasound manifestations and imaging characteristics, and analyze the prognosis of the fetus.In all cases, fetal ductus arteriosus premature constriction occurred in the third trimester of pregnancy (34 + 1 to 41 weeks), and no abnormality in extracardiac organs were observed. Seven neonates required respiratory support due to the accompanying severe tricuspid regurgitation. The remaining 15 neonates did not receive respiratory support, including 4 with severe tricuspid regurgitation, 5 with moderate regurgitation, and 6 with mild regurgitation. Significant differences were observed in the fetal right atrium size and tricuspid regurgitation severity between the neonatal respiratory support group and non-respiratory support group. Furthermore, there were statistical differences in the ductus arteriosus inner diameter and pulsation index between the two groups.The severity of fetal ductus arteriosus premature contraction accompanied by tricuspid regurgitation and right atrium enlargement can predict the immediate prognosis of the newborn and provide guidance for the clinical judgment of the timing of pregnancy termination.

Cardiac Function Assessment in Fetuses With Ductus Arteriosus Constriction: A Two-Dimensional Echocardiography and FetalHQ Study

Background

Fetal ductal constriction (DC) is associated with excessive polyphenol-rich food (PRF) consumption during pregnancy. However, the effect of this hemodynamic change on fetal cardiac function still needs to be elucidated. Therefore, this study aimed to evaluate the cardiac function of fetuses with PRF-related DC and to describe serial observations of cardiac function changes.

Methods

We compared the traditional echocardiographic indices, including morphological, hemodynamic, and functional parameters, between study fetuses and controls. For global and segmental deformation analysis of the left and right ventricles, fetalHQ with the speckle-tracking technique was used to calculate sphericity index (SI), global longitudinal strain (GLS), fractional shortening (FS), fractional area change (FAC), etc. In addition, follow-up data were compared with the generalized linear model.

Results

A total of 60 DC fetuses and 60 gestational-matched controls were enrolled in our study, with 20 DC fetuses undertaking a follow-up echocardiogram after 2–3 weeks. Compared with controls, there was a distinct decrease in right ventricular GLS (RVGLS) (−13.39 ± 3.77 vs. −21.59 ± 2.51, p < 0.001), RVFAC (22.20 ± 9.56 vs. 36.01 ± 4.84, p < 0.001), left ventricular GLS (LVGLS) (−19.52 ± 3.24 vs. −23.81 ± 2.01 p < 0.001), and LVFAC (39.64 ± 7.32 vs. 44.89 ± 4.91, p = 0.004). For 24-segment FS analysis, DC fetuses showed lower FS in left ventricular (LV) segments 18–24, with no difference in LV segments 1–17. Right ventricular (RV) FS in segments 4–23 was also reduced in the DC group. The 24-segment SI analysis indicated significantly lower SI in DC than those in controls for LV segments 1–14 and RV segments 19–24. We found that the pulsatility index (PI) of ductus arteriosus (DA) was an independent variable for RVGLS (β = −0.29, p = 0.04). In 20 DC fetuses with follow-up echocardiograms, no obvious difference in myocardial deformation was found between the initial examination and follow-up data.

Conclusion

Left and right ventricular performances were both impaired in DC fetuses, along with a series of morphological and hemodynamic changes. Although the state of DA constriction improved on second examinations, cardiac function was not completely restored.

Case Report: Persistent Pulmonary Hypertension of the Newborn and Narrowing of the Ductus Arteriosus After Topical Use of Non-Steroidal Anti-Inflammatory During Pregnancy

Background: The use of non-steroidal anti-inflammatory drugs (NSAIDs) during the third trimester of pregnancy can cause premature constriction of the ductus arteriosus. This report describes a case of in utero narrowing of the ductus arteriosus (DA) diagnosed postnatally in a baby with Persistent Pulmonary Hypertension of the Newborn (PPHN), after maternal use of Diclofenac-Epolamine 140 mg patch during the second and third trimester.

Case Presentation: A fetal ultrasounds revealed an enlarged hypertrophic right ventricle at 32 weeks of gestation. Detailed questioning of the mother highlighted that topical Diclofenac (FLECTOR^®) had been used at 26 and at 31 weeks of gestation. An echocardiography performed 8 h postnatally showed supra-systemic pulmonary hypertension, a restrictive ductus arteriosus and a dilated right ventricle. The newborn was treated by inhaled nitric oxide and oral Sildenafil and was discharged from hospital on day 24. He had a complete normalization of his pulmonary vascular resistance on day 48.

Conclusion: This case illustrates the potential fetal and neonatal complications associated with maternal topical Diclofenac medication during pregnancy resulting in antenatal closure of the DA.

Foetal ductus arteriosus constriction unrelated to non-steroidal anti-Inflammatory drugs: a case report and literature review

Foetal ductus arteriosus (DA) constriction can be found in complex foetal heart malformations, but rarely as an isolated defect. Although many cases of DA constriction are usually related to Non-steroidal Anti-Inflammatory Drugs (NSAIDs) maternal intake, other causes remain without an established aetiology and are referred to as idiopathic. Recently, a wide range of risks factors or substances (polyphenol-rich foods intake, naphazoline, fluoxetine, caffeine and pesticides) showed a definitive effect upon the pathway of inflammation, causing DA constriction. We report a case of a premature DA constriction in a woman whose possible risk factor was identified in her maternal occupational exposure to solvents and a comprehensive literature review of 176 cases of NSAID-unrelated DA constriction. A 30-year-old Asian woman was referred to our institution at 33 gestational weeks and 0 days because of suspicion of premature DA constriction. The woman had no history of medication intake, including NSAIDs, alcohol, tobacco or polyphenol-rich-food consumption during pregnancy. A detailed foetal echocardiography revealed a normal cardiac anatomy with hypertrophic, hypokinetic and a dilated right ventricle due to right pressure overload, holosystolic tricuspid regurgitation, and, at the level of the DA, high systolic and diastolic velocities, indicating premature ductal restriction. The right outflow showed dilatation of the pulmonary artery with narrow DA. An urgent caesarean section was performed at 33 gestational weeks and 4 days due to worsening of DA PI and signs of right pressure overload, despite the interruption of exposure to solvents. We assume a relationship exists between premature DA constriction and a maternal occupational exposure to solvents. This hypothesis is reinforced by the presence of associated foetal malformations in in two of the patient's children. Further research is needed to confirm the role of exposure to solvents and toxic chemicals in the pathogenesis of DA constriction, also with experimental animal models.KEY MESSAGESMany cases of DA constriction are usually related to Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) maternal intake.A wide range of risks factors or substances (polyphenol-rich foods intake, naphazoline, fluoxetine, caffeine and pesticides) can cause foetal DA constriction.Further investigation are needed to confirm the role of maternal exposure to solvents in the pathogenesis of DA constriction.

Clinical features and echocardiographic findings of isolated foramen ovale restriction in foetuses

Isolated restrictive foramen ovale (rFO) without complex heart defects is a rare pathology. There may be difficulties in managing this situation, which can lead to right heart enlargement, tricuspid regurgitation and hydrops findings in the foetus. We conducted a retrospective analysis of 8451 foetuses. 7883 (93.2%) had a structurally normal heart or minor heart disease, 18 (0.22%) of which had a diagnosis of isolated rFO. Nine patients with neonatal echocardiographic examination were included in the study. In 8 (88.8%) patients, it was stated that a decision to give birth should be made at the time of presentation. Evaluating postpartum echocardiographic examinations, 7 (77.7%) patients had normal or minor defects. The decision of delivery made at the right time during follow-up is critical to determine the prognosis.IMPACT STATEMENTWhat is already known on this subject? The data about the prenatal diagnosis of isolated rFO is limited.What the results of this study add? We conducted a retrospective analysis of 8451 foetuses. 7883 (93.2%) foetuses had a structurally normal heart or minor heart disease, 18 (0.22%) of which had a diagnosis of rFO. Nıne patients with foetal and postnatal follow-up and echocardiographic findings were examined in the study. The group's median gestational age at admission was 35.0 weeks (range: 27.0-39.0 weeks). The delivery decision was made in 8 (88.8%) patients at the time of admission. Evaluating postpartum echocardiographic examinations, 7 (77.7%) patients had normal or minor defects. Additionally, one patient was diagnosed with cardiomyopathy, and the other patient was diagnosed with functional pulmonary atresia. No death occurred in any foetus during follow-up.What the implications are of these findings for clinical practice and/or further research? Isolated rFO, a rare condition in the foetus, is generally well-tolerated in foetal life. However, the right heart enlargement, tricuspid regurgitation, or hydrops findings can be seen in patients. The decision of delivery made at the right time during follow-up is critical to determine the prognosis.

Isolated Dissection of the Ductus Arteriosus Associated with Sudden Unexpected Intrauterine Death

We report five cases of sudden intrauterine death due to premature closure of the ductus arteriosus. In four cases, this was caused by dissecting the hematoma of the ductus arteriosus with intimal flap and obliteration of the lumen. In one case, the ductus arteriosus was aneurysmatic, with lumen occlusion caused by thrombus stratification. No drug therapy or free medication consumption were reported during pregnancy. The time of stillbirth ranged between 26 and 33 gestational weeks. We performed TUNEL analysis for apoptosis quantification. The dissecting features were intimal tears with flap formation in four of the cases, just above the origin of the ductus arteriosus from the pulmonary artery. The dissecting hematoma of the ductus arteriosus extended downward to the descending aorta and backward to the aortic arch with involvement of the left carotid and left subclavian arteries. TUNEL analysis showed a high number of apoptotic smooth muscle cells in the media in two cases. Abnormal ductal remodeling with absence of subintimal cushions, lacunar spaces rich in glycosaminoglycans (cystic medial necrosis), and smooth muscle cell apoptosis were the pathological substrates accounting for failure of remodeling process and dissection.

Management of acute and recurrent pericarditis in pregnancy

This review summarizes the currently available evidence on the management of acute and recurrent pericarditis during pregnancy, focusing on the safety of diagnostic procedures and treatment options for the mother and foetus. Family planning should be addressed in women with recurrent pericarditis of reproductive age and adjustment of therapy should be considered before a planned pregnancy. The treatment of pericarditis in pregnancy is similar to that for non-pregnant women but considers current knowledge on drug safety during pregnancy and lactation. The largest case series on this topic described 21 pregnancies with idiopathic recurrent pericarditis. Pregnancy should be planned in a phase of disease quiescence. Non-steroidal anti-inflammatory drugs can be used at high dosages until the 20th week of gestation (except low-dose aspirin 100 mg/die). Colchicine is allowed until gravindex positivity; after this period, administration of this drug during pregnancy and lactation should be discussed with the mother if its use is important to control recurrent pericarditis. Prednisone is safe if used at low-medium doses (2,5 - 10 mg/die). General outcomes of pregnancy in patients with pericarditis are good when the mothers are followed by a multidisciplinary team with experience in the field.

Persistent pulmonary hypertension of the newborn

Persistent pulmonary hypertension of the newborn (PPHN) is a significant clinical problem characterized by refractory and severe hypoxemia secondary to elevated pulmonary vascular resistance resulting in right-to-left extrapulmonary shunting of deoxygenated blood. PPHN is associated with diverse cardiopulmonary disorders and a high early mortality rate for infants with severe PPHN. Surviving infants with PPHN have an increased risk of long-term morbidities. PPHN physiology can be categorized by (1) maladaptation: pulmonary vessels have normal structure and number but have abnormal vasoreactivity; (2) excessive muscularization: increased smooth muscle cell thickness and increased distal extension of muscle to vessels that are usually not muscularized; and (3) underdevelopment: lung hypoplasia associated with decreased pulmonary artery number. Treatment involves adequate lung recruitment, optimization of cardiac output and left ventricular function, and pulmonary vasodilators such as inhaled nitric oxide. Infants who fail to respond to conventional therapy should be evaluated for lethal lung disorders including alveolar-capillary dysplasia, T-box transcription factor 4 gene, thyroid transcription factor-1, ATP-binding cassette A3 gene, and surfactant protein diseases.

Catheter-Guided Dissolution of a Giant Thrombus in the Left Ventricle in a Newborn

A newborn with pulmonary hypertension due to the premature fetal arterial duct occlusion was diagnosed with a giant left ventricle thrombus. Cardiopulmonary compromise required multidrug therapy with vasopressors infusions, high-frequency oscillation, and nitric oxide. Alteplase infusion through a guiding catheter into the left atrium dissoluted the clot without sequelae. (Level of Difficulty: Advanced.)

Maternal paracetamol intake and fetal ductus arteriosus constriction/closure: comprehensive signal evaluation using the Austin Bradford Hill criteria

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 H_O) versus (2) APAP may in some cases be at least a contributory cause of in utero DA narrowing (alternative hypothesis or H_A) to justify risk communication.

METHODS

To assess the relative support for H_O versus H_A, 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 H_A 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.

Prenatal duct closure leading to severe pulmonary hypertension in a preterm neonate-a case report

Prenatal closure of the ductus arteriosus (DA) can lead to cardiovascular dysfunction resulting in pulmonary hypertension (PH), progressive right heart failure, fetal hydrops, and fetal or neonatal demise. Supportive therapies-including mechanical ventilation, oxygen, and nitric oxide (NO)-have been employed with variable success among infants born full term, but there is no widely accepted management of prenatal closure of the DA, particularly for preterm infants. We present the case of an infant born at 31 weeks' gestation with right ventricular (RV) dysfunction and PH due to prenatal ductal closure, who was successfully treated with milrinone, resulting in full recovery of cardiac function. Prenatal ductal closure is rare, particularly under 32 weeks gestation, but should be suspected in cases of postnatal hypoxemia in the absence of significant lung disease or structural heart disease. Milrinone may be considered as a therapeutic agent to treat both PH and RV dysfunction in preterm infants status post in utero closure of the DA.

Prenatally diagnosed case of tricuspid valve dysplasia: A case report with review of the literature

We present a case of fetal tricuspid valve dysplasia (TVD) and pulmonary atresia, diagnosed during a routine obstetric ultrasound scan. Serial fetal echocardiographic evaluations revealed progressively augmented prodigious thickening of the tricuspid valvular and subvalvular structures, which eventually extensively obliterated the right ventricle cavity. Thickened dysplastic valve displayed a "cotton-wool" appearance. Unusual configurations of three vessels in the three-vessel view were also observed on a consecutive gray scale and color Doppler scans. During pregnancy, the fetus exhibited satisfactory growth parameters, and complications of progressive hemodynamic compromise associated with TVD and pulmonary atresia such as grievous hydrops or arrhythmia did not develop till 39 weeks of gravidity.

In-utero idiopathic ductal constriction: a prenatal manifestation of Alagille and Williams syndrome arteriopathy

OBJECTIVE

Williams and Alagille syndromes are genetic disorders associated with pathologic arterial narrowing. We hypothesized that fetal idiopathic ductus arteriosus (DA) constriction may represent a prenatal manifestation of the arteriopathy associated with these syndromes.

METHODS

Multi-institutional case series review of the pre- and postnatal medical records, echocardiograms, and genetic test results of fetuses presenting with idiopathic DA constriction.

RESULTS

We identified four cases of idiopathic fetal DA constriction at 21-36 weeks of gestation. All had right ventricular hypertension, dilation, hypertrophy, and dysfunction and either DA constriction or absence. All demonstrated progressive peripheral pulmonary artery stenosis after birth. Three met clinical diagnostic criteria for Alagille syndrome; two tested had confirmatory JAG1 mutations. One also developed supravalvar aortic stenosis after birth and was positive for 7q11.23 deletion (Williams syndrome).

CONCLUSION

This is the first case series to suggest that idiopathic fetal DA constriction may be a prenatal manifestation of genetic arteriopathy.

Ductus arteriosus and fetal echocardiography: Implications for practice

The ductus arteriosus (DA) is a crucial part of the fetal circulation, both in the normal fetus and in critical congenital heart disease (CHD). It allows shunting between the pulmonary and systemic circulations. In physiological prenatal conditions, the DA lets the majority of right ventricular output bypass the fluid-filled, high-resistance lungs. The DA can cause hemodynamic compromise in the fetus and neonate when constricted or absent (in isolation or in patients with CHD) and may lead to pre- or postnatal sequelae within other systems when forming part of a vascular ring. In CHD, the DA can be interrogated by fetal echocardiography to infer information regarding severity of pulmonary outflow tract obstruction, adequacy of the sub-pulmonary ventricle to supply pulmonary blood flow, and to predict the likelihood of atrial septum restriction in transposition of the great arteries. A good understanding of the DA is crucial for fetal cardiologists.

Dysfunction of the foetal arterial duct results in a wide spectrum of cardiovascular pathology

OBJECTIVE

Foetal ductal problems may have various cardiopulmonary consequences. This study aimed to identify the spectrum of ductus arteriosus (DA) dysfunction (closure, constriction, kinking, aneurysm and thrombosis) and the resultant clinical and echocardiographic presentation in foetuses and neonates.

METHODS AND RESULTS

This is a retrospective analysis of serial pre- and post-natal data of 27 cases of foetal ductal dysfunction diagnosed at a median gestational age of 33 weeks (range 20-39). The most common abnormalities observed were premature closure of the DA in 56% (15/27) and constriction in 29% (8/27). Right ventricular hypertrophy was present in 75% (n = 11/15) of foetuses with premature DA closure, while ventricular dilation (4/7, 57%) was a more common feature in foetuses with ductal constriction. After birth, 63% (17/27) of new borns presented with cyanosis and pulmonary hypertension that required active treatment. Three infants died after birth. Abnormalities resolved spontaneously after birth in about 50% of patients. In some children, pulmonary valve stenosis and regurgitation was progressive and required further treatment.

CONCLUSIONS

An abnormal right heart on foetal four-chamber ultrasound view should alert the sonographer to the possible presence of foetal ductal dysfunction. Ductal occlusion, transient or fixed constriction, kinking and aneurysm formation are associated with foetal cardiopulmonary sequelae. Symptoms and pathology is probably related to the type, foetal age, rapidity of progression and duration of intrauterine ductal dysfunction. Correspondingly, clinical outcomes vary ranging from little or no symptoms to severe respiratory distress and even foetal or neonatal death.

Bronchopulmonary dysplasia: A review of pathogenesis and pathophysiology

Bronchopulmonary dysplasia (BPD) is a chronic lung disease of primarily premature infants that results from an imbalance between lung injury and repair in the developing lung. BPD is the most common respiratory morbidity in preterm infants, which affects nearly 10, 000 neonates each year in the United States. Over the last two decades, the incidence of BPD has largely been unchanged; however, the pathophysiology has changed with the substantial improvement in the respiratory management of extremely low birth weight (ELBW) infants. Here we have attempted to comprehensively review and summarize the current literature on the pathogenesis and pathophysiology of BPD. Our goal is to provide insight to help further progress in preventing and managing severe BPD in the ELBW infants.

Prognostic factors of premature closure of the ductus arteriosus in utero: a systematic literature review

BACKGROUND

A number of case reports show various outcomes of premature closure of the ductus arteriosus in utero, including persistent pulmonary hypertension of the newborn and fetal or neonatal death; however, no study clarifies the clinical observations that are related to their prognoses. We aimed to clarify the prognostic factors of intrauterine ductal closure by a systematic literature review. Data sources We searched PubMed database (1975-2014) to identify case reports and studies on intrauterine closure of the ductus arteriosus, including maternal, fetal, and neonatal clinical information and their prognoses.

RESULTS

We analysed the data of 116 patients from 39 articles. Of these, 12 (10.3%) died after birth or in utero. Fetal or neonatal death was significantly correlated with fetal hydrops (odds ratio=39.6, 95% confidence interval=4.6-47.8) and complete closure of the ductus arteriosus (odds ratio=5.5, 95% confidence interval=1.2-15.1). Persistent pulmonary hypertension was observed in 33 cases (28.4%), and was also correlated with fetal hydrops (odds ratio=4.2, 95% confidence interval=1.3-4.6) and complete closure of the ductus arteriosus (odds ratio=5.5, 95% confidence interval=1.6-6.0). Interestingly, maternal drug administration was not correlated with the risk of death and persistent pulmonary hypertension.

CONCLUSIONS

Fetal hydrops and complete ductal closure are significant risk factors for both death and persistent pulmonary hypertension. Cardiac or neurological prognoses could be favourable if the patients overcome right heart failure during the perinatal period.

Left Ventricular Noncompaction in Older Patients

BACKGROUND

Information on left ventricular noncompaction (LVNC) in older people is sparse. This study aimed to investigate the clinical profile of LVNC in an older cohort.

MATERIALS AND METHODS

Between August 2007 and September 2015, older patients (age ≥ 60 years) who were diagnosed with LVNC using cardiovascular magnetic resonance were prospectively enrolled at our hospital.

RESULTS

A total of 35 patients (male, 80%; mean age, 65 ± 5 years) were prospectively included in this study. LVNC was not detected in 18 patients (51%) at the initial echocardiographic evaluation. Of the 21 patients who received coronary imaging, 8 patients (38%) had coronary artery disease. Left ventricular (LV) dysfunction and dilation were detected in 31 patients (89%) and 30 patients (86%), respectively. Nine patients (26%) died during a follow-up period of 2.9 ± 2.3 years. Cox analysis showed that patients with syncope (hazard ratio [HR] = 20.51; 95% CI: 1.70-246.60; P = 0.02), increased LV end-diastolic diameter (HR = 1.12; 95% CI: 1.01-1.24; P = 0.03), decreased LV ejection fraction (HR = 0.87; 95% CI: 0.77-0.98; P = 0.02) and the presence of late gadolinium enhancement on cardiovascular magnetic resonance (HR = 8.9; 95% CI: 1.07-74.08; P = 0.04) had a higher risk for death.

CONCLUSIONS

The diagnosis of LVNC is easily missed at echocardiographic assessment in older patients. Coronary artery disease is a common concomitant disorder in these patients. Older patients with LVNC have a high risk for mortality. Syncope, LV dilation, systolic dysfunction and late gadolinium enhancement are related to adverse outcomes in older patients.

Original paper. Do Umbilical Cord Wrapped Around the Fetal Body Can Mimic Signs of Aortal Coarctation?

Objectives: Coarctation of the aorta (CoA) is an irreversible congenital heart defect. Its prenatal diagnosis is not rare a subject to false-positive conclusion. We present a novel hypothesis explaining the basis of this error.

Methods: Ten cases of prenatal suspicion of the coarctation of the aorta (based on disproportion at the level of 4 chamber view and mediastinum) coincidenced with the umbilical cord wrapped around the fetal body were found in the Filemaker datebase of the Fetal Cardiology Department. Only single pregnancies were taken into account. In all cases another cardiac and extracardiac malformations were excluded.

Results: The mean maternal age was 29,6 years. The mean gestational age was 33 7/8 weeks. All fetuses were in a good cardiovascular condition. The usual position of the umbilical cord was neck, but they were also location such as nucha, abdomen or lower limb. At birth, all newborns had normal anatomy of the heart. We conclude that the explanation of the false diagnosis was haemodynamic, resulting from the compression of the fetal neck by the umbilical cord that resulted in a disproportion of cardiac blood flow, “mimicking” CoA.

Conclusions:

1. Functional disturbances can mimic prenatal CoA.

2. Umbilical cord position (specially enlacing the fetus neck) should be taken into consideration in suspected cases of fetal CoA.

[Maternal use of non-steroidal antiinflammatory drugs and closure of the ductus arteriosus]

Nous rapportons un cas de fermeture prématurée in utero du canal artériel diagnostiqué chez un fœtus en état d’anasarque avec insuffisance cardiaque majeure après prise d’anti-inflammatoire non stéroïdiens (AINS) par la mère. Une échographie obstétricale au deuxième trimestre a permis la découverte d’une asymétrie des cavités cardiaques. L’indication de césarienne a été posée à 30 semaines d’aménorrhées devant un fœtus en état d’anasarque avec insuffisance cardiaque majeure sur une fermeture anténatale du canal artériel. A partir de ce cas nous nous proposons de réaliser une revue de la littérature pour illustrer les complications fœtales et néonatales potentielles résultant de la fermeture précoce du canal artériel secondaire à la prise d’AINS pendant la grossesse.

Pulmonary hypertension's variegated landscape: a snapshot

The many types of pulmonary hypertension (PH) are so protean in their biological origin, histological expression, and natural history that it is difficult to create a summary picture of the disease, or to easily compare and contrast characteristics of one type of PH with another. For newcomers to the field, however, such a picture would facilitate a broad understanding of PH. In this paper, we suggest that four characteristics are fundamental to describing the nature of various types of PH, and that taken together they define a number of patterns of PH expression. These characteristics are histopathology, developmental origin, associated clinical conditions, and potential for resolution. The “snapshot” is a way to concisely display the ways that these signal characteristics intersect in select specific types of PH, and is an effort to summarize these patterns in a way that facilitates a “big picture” comprehension of this disease.

Left Ventricular Non-Compaction: A Cardiomyopathy With Acceptable Prognosis in Children

BACKGROUND

Data on children with left ventricular non-compaction (LVNC) is sparse. The purpose of this study was to evaluate its clinical profiles in a population of Chinese children.

METHODS

From January 2010 to March 2016, consecutive Chinese children (aged <18 years) with LVNC diagnosed by cardiovascular magnetic resonance (CMR) were prospectively recruited at Fuwai Hospital.

RESULTS

A total of 41 Chinese children (male: 28%; mean age: 14±4years) were included in this study. Left ventricular non-compaction was not detected in 13 (32%) patients at initial echocardiographic evaluation. Congenital heart disease (CHD) was found in 11 (27%) patients. Four (10%) patients had Wolff-Parkinson-White (WPW) syndrome. Mean left ventricular ejection fraction (LVEF) was 41±15%. Late gadolinium enhancement (LGE) was detected in eight (20%) subjects. During a mean follow-up of 2.9 years, four (9%) patients died or received heart transplantation. These patients had lower systolic blood pressure (91±10 vs. 108±14mmHg; p=0.02), diastolic blood pressure (57±7 vs. 68±8mmHg; p=0.007) and LVEF (19±7 vs. 44±12%; p=0.002) than the survivors. In addition, advanced heart failure (100% vs. 16%; p=0.002) and LGE (50% vs. 5%; p=0.04) were detected more in these subjects.

CONCLUSIONS

Left ventricular non-compaction is easily overlooked at echocardiographic assessment. Congenital heart disease and WPW syndrome were relatively common in LVNC children. The prognosis of children with LVNC seemed to be better than previous studies reported, and its long-term prognosis needs to be further investigated.

Selective serotonin reuptake inhibitor exposure constricts the mouse ductus arteriosus in utero

Use of selective serotonin reuptake inhibitors (SSRIs) is common during pregnancy. Fetal exposure to SSRIs is associated with persistent pulmonary hypertension of the newborn (PPHN); however, a direct link between the two has yet to be established. Conversely, it is well known that PPHN can be caused by premature constriction of the ductus arteriosus (DA), a fetal vessel connecting the pulmonary and systemic circulations. We hypothesized that SSRIs could induce in utero DA constriction. Using isolated vessels and whole-animal models, we sought to determine the effects of two commonly prescribed SSRIs, fluoxetine and sertraline, on the fetal mouse DA. Cannulated vessel myography studies demonstrated that SSRIs caused concentration-dependent DA constriction and made vessels less sensitive to prostaglandin-induced dilation. Moreover, in vivo studies showed that SSRI-exposed mice had inappropriate DA constriction in utero. Taken together, these findings establish that SSRIs promote fetal DA constriction and provide a potential mechanism by which SSRIs could contribute to PPHN.

Thoracic epidural analgesia to control malignant pain until viability in a pregnant patient

Management of nonobstetric pain in the pregnant patient presents unique challenges related to transplacental fetal exposure to opioids and the subsequent risk of neonatal withdrawal syndrome. We present the case of a pregnant patient suffering from the pain of a progressively enlarging thoracoabdominal sarcoma. Epidural analgesia (using local anesthetics with minimal opioid) was utilized over a span of weeks to manage oncologic pain, limiting fetal opioid exposure and culminating in the birth of a healthy infant. While nonobstetric abdominal pain during pregnancy is not that uncommon, neoplastic abdominal pain does appear to be rare. Combined local anesthetic and opioid continuous epidural infusion should be considered a viable option in the pain management approach to obstetric patients with nonobstetric pain associated with malignancy.

Fetal Ventricular Hypertrabeculation/Noncompaction: Clinical Presentation, Genetics, Associated Cardiac and Extracardiac Abnormalities and Outcome

Left ventricular hypertrabeculation/noncompaction (LVHT) is a cardiac abnormality of unknown etiology. Aim of the review was to summarize the current knowledge about fetal LVHT, including clinical presentation, associated cardiac and extracardiac abnormalities and outcome. In 88 cases, LVHT was diagnosed by fetal echocardiography. In 36 %, no additional cardiac abnormalities were reported; in the remaining 64 %, one or more cardiac abnormalities were reported. Eight cases died prenatally, 17 were electively terminated, and 24 patients died after birth. Six patients were lost to follow-up, and 33 patients are alive at a mean age of 26 months. Surviving cases presented less frequently with fetal hydrops (13 vs. 62 %, p = 0.0004), complete heart block (27 vs. 78 %, p = 0.0076), more than three associated cardiac abnormalities (9 vs. 47 %, p = 0.0008) and more frequently with isolated LVHT (52 vs. 19 %, p = 0.009) than cases who died. Of the surviving patients, 16 received pharmacotherapy, three received pacemakers, eight underwent surgical procedures and four underwent heart transplantation. Postnatal regression of left ventricular hypertrophy and development of LVHT was found in four cases, improvement in cardiac function in two, and regression of right VHT in two. At autopsy, endocardial fibrosis was the most frequent abnormality in 92 %. Thirty-eight percentage of cases with fetal LVHT survived. Fetal and postnatal echocardiographic findings challenge the "embryonic pathogenetic" hypothesis of LVHT. Furthermore, fetal pathoanatomic findings like endocardial fibrosis might play a role in clarifying the still unsolved pathogenesis of LVHT.

Diagnosis and management of fetal ductus arteriosus constriction-closure

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.

MRI shows limited mixing between systemic and pulmonary circulations in foetal transposition of the great arteries: a potential cause of in utero pulmonary vascular disease

OBJECTIVES

To investigate the relationship between foetal haemodynamics and postnatal clinical presentation in patients with transposition of the great arteries using phase-contrast cardiovascular magnetic resonance.

BACKGROUND

A severe and irreversible form of persistent pulmonary hypertension of the newborn occurs in up to 5% of patients with transposition and remains an important cause of morbidity and mortality in these infants. Restriction at the foramen ovale and ductus arteriosus has been identified as a risk factor for the development of pulmonary hypertension, and this can now be studied with magnetic resonance imaging using a new technique called metric optimised gating.

METHODS

Blood flow was measured in the major vessels of four foetuses with transposition with intact ventricular septum (gestational age range: 35-38 weeks) and compared with values from 12 normal foetuses (median gestational age: 37 weeks; range: 34-40 weeks).

RESULTS

We found significantly reduced flows in the ductus arteriosus (p<0.01) and foramen ovale (p=0.03) and increased combined ventricular output (p=0.01), ascending aortic (p=0.001), descending aortic (p=0.03), umbilical vein (p=0.03), and aorto-pulmonary collateral (p<0.001) flows in foetuses with transposition compared with normals. The foetus with the lowest foramen ovale shunt and highest aorto-pulmonary collateral flow developed fatal pulmonary vascular disease.

CONCLUSIONS

We found limited mixing between the systemic and pulmonary circulations in a small group of late-gestation foetuses with transposition. We propose that the resulting hypoxia of the pulmonary circulation could be the driver behind increased aorto-pulmonary collateral flow and contribute to the development of pulmonary vascular disease in some foetuses with transposition.

Prenatal sonographic diagnosis of premature constriction of the fetal ductus arteriosus after maternal self-medication with benzydamine hydrochloride: report of 3 cases and review of the literature

We report 3 cases of prenatal diagnosis of premature constriction of the ductus arteriosus after maternal benzydamine hydrochloride therapy (3-mg lozenges) in third-trimester pregnancies. In each case, fetal echocardiography revealed a dilated, hypocontractile right ventricle with severe tricuspid regurgitation and constriction of the ductus arteriosus. Although the effect of indomethacin and other nonsteroidal anti-inflammatory drugs on prenatal ductal constriction is well known, readily available over-the-counter nonsteroidal anti-inflammatory drugs such as benzydamine can have an equally deleterious effect and are best avoided in the third trimester of pregnancy.

Diagnostic ultrasound features and outcome of restrictive foramen ovale in fetuses with structurally normal hearts

Intrauterine foramen ovale (FO) restriction in association with congenital heart disease (CHD) carries a poor prognosis. However, in the absence of CHD, the clinical importance of restrictive FO in the fetus is not well understood. We evaluated the antenatal prevalence, clinical presentation, diagnostic ultrasound features, and outcome of restrictive FO in fetuses without CHD. We reviewed the echocardiographic and clinical records of 23 fetuses diagnosed with a restrictive FO and structurally normal heart between 2001 and 2012. The atrial septum, dimensions of cardiac structures, left and right cardiac output and Doppler interrogation of cardiac flows were examined. The clinical outcomes of all fetuses with restrictive FO were analysed. Restrictive FO was identified in 23 of 1,682 (1.4%) fetuses with no CHD. Enlarged right heart structures (100%), hypermobile or redundant primum atrial septum (91%), increased right-to-left ventricular cardiac output ratio (91%), and posteriorly angulated ductus arteriosus (68%) were the most common echocardiographic findings associated with this rare phenomenon. Additional noncardiac systemic abnormalities were identified in 13 (56%) babies. Seven (30%) neonates developed persistent pulmonary hypertension, and 7 infants died. Antenatal restrictive FO is an underrecognised entity despite being a common cause of right heart dilatation in the fetus. In the absence of CHD, restrictive FO is well tolerated antenatally, but its frequent association with noncardiac abnormalities and pulmonary hypertension in the neonate are noteworthy.

Maternal diclofenac medication in pregnancy causing in utero closure of the fetal ductus arteriosus and hydrops

This report describes a case of premature closure in utero of the ductus arteriosus (DA) diagnosed postnatally in a baby with hydrops and cardiac failure. An echocardiogram 6 h postnatally showed marked dilation of the right atrium and right ventricle with marked hypertrophy and impaired function, elevated pulmonary pressures, a small pericardial effusion, and no flow through the DA. The mother was unaware of her pregnancy until she presented in labor, and she had taken diclofenac medication in the preceding months. This case and the accompanying literature review illustrate the potential fetal and neonatal complications resulting from antenatal closure of the DA due to maternal diclofenac medication during pregnancy.

Neonatal circulatory failure due to acute hypertensive crisis: clinical and echocardiographic clues

OBJECTIVE

Circulatory failure due to acute arterial hypertension in the neonatal period is rare. This study was undertaken to assess the clinical and echocardiographic manifestations of circulatory failure resulting from acute neonatal hypertensive crisis.

METHODS

Neonatal and cardiology databases from 2007 to 2010 were reviewed. An established diagnosis of circulatory failure due to neonatal hypertension before the age of 14 days was required for inclusion. Six patients were identified.

RESULTS

Five patients presented with circulatory failure due to an acute hypertensive crisis. The median age at presentation was 8.5 days (range: 6.0-11.0) with a median body weight of 3.58 kg (range: 0.86-4.70). Echocardiography demonstrated mild left ventricular dysfunction [median shortening fraction (SF) 25%, range 10-30] and mild aortic regurgitation in 83% (5/6) of patients. One patient with left ventricular dysfunction (SF = 17%) had a large apical thrombus. Two patients were hypotensive, and hypertension only became evident after restoration of cardiac output. Administration of intravenous milrinone was successful, with rapid improvement of the clinical condition. Left ventricular function normalised in all survivors.

CONCLUSION

Early neonatal circulatory collapse due to arterial hypertension is a rare but potentially life-threatening condition. At presentation, hypotension, especially in the presence of a dysfunctional left ventricle, does not exclude a hypertensive crisis being the cause of circulatory failure. The echocardiographic presence of mild aortic regurgitation combined with left ventricular hypocontractility in a structurally normal heart should alert the physician to the presence of underlying hypertension.

A case of progressive ductal constriction in a fetus

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.

Maternal restriction of polyphenols and fetal ductal dynamics in normal pregnancy: an open clinical trial

BACKGROUND

We have recently demonstrated reversal of fetal ductal constriction after dietary maternal restriction of polyphenol-rich foods (PRF), due to its inhibitory action on prostaglandin synthesis.

OBJECTIVE

To test the hyphotesis that normal third trimester fetuses also improve ductus arteriosus dynamics after maternal restriction of polyphenols.

METHODS

Open clinical trial with 46 fetuses with gestational age (GA) > 28 weeks submitted to 2 Doppler echocardiographic studies with an interval of at least 2 weeks, being the examiners blinded to maternal dietary habits. A validated food frequency questionnaire was applied and a diet based on polyphenol-poor foods (<30 mg/100 mg) was recommended. A control group of 26 third trimester fetuses was submitted to the same protocol. Statistics used t test for independent samples.

RESULTS

Mean GA was 33 ± 2 weeks. Mean daily maternal estimated polyphenol intake (DMPI) was 1277 mg, decreasing to 126 mg after dietary orientation (p=0.0001). Significant decreases in systolic (SDV) and diastolic (DDV) ductal velocities, and RV/LV diameters ratio, as well as increase in ductal PI were observed [DSV = 1.2 ± 0.4 m/s (0.7-1.6) to 0.9 ± 0.3 m/s (0.6-1.3) (p = 0.018); DDV = 0.21 ± 0.09 m/s (0.15-0.32) to 0.18 ± 0.06 m/s (0.11-0.25) (p = 0.016); RV/LV ratio = 1.3 ± 0.2 (0.9-1.4) to 1.1 ± 0.2 (0.8-1.3) (p=0.004); ductal PI = 2.2 ± 0.03 (2.0-2.7) to 2.4 ± 0.4(2.2-2.9) (p = 0.04)]. In the control group, with GA of 32 ± 4 weeks, there were no significant differences in DMPI, mean SDV, DDV, PI and RV/LV ratio.

CONCLUSION

The oriented restriction of third trimester maternal ingestion of polyphenol-rich foods for a period of 2 weeks or more improve fetal ductus arteriosus flow dynamics and right ventricular dimensions.

Reversal of fetal ductal constriction after maternal restriction of polyphenol-rich foods: an open clinical trial

OBJECTIVE

To test the hypothesis that maternal restriction of polyphenol-rich foods (PRF), which, like non-steroidal anti-inflammatory drugs (NSAID), inhibit prostaglandin synthesis in the third trimester, reverse fetal ductal constriction (DC).

STUDY DESIGN

An open clinical trial of 51 third trimester fetuses with DC with no history of NSAID intake was designed. All mothers were submitted to a food frequency questionnaire and were oriented to withdrawl PRF, being reassessed after 3 weeks. Doppler parameters were assessed before and after discontinuation of these substances. A control group of 26 third trimester normal fetuses, with no ductus arteriosus (DA) constriction, in which no dietary intervention was offered, was reviewed after 3 weeks. Student's t-test and Wilcoxon's test were used.

RESULT

Mean gestational age was 32±3 weeks (28 to 37 weeks). After discontinuation of PRF (≥3 weeks), 48/51 fetuses (96%) showed complete reversal of DC, with decrease in mean ductal systolic velocity (1.74±0.20 m s(-1) to 1.31±0.34 m s(-1), P<0.001), mean diastolic velocity (0.33±0.09 m s(-1) to 0.21±0.07 m s(-1), P<0.001) and mean right to left ventricular dimension ratio (1.37±0.26 to 1.12±0.17, P<0.001) and increase in mean ductal pulsatility index (PI) (1.98±0.36 to 2.46±0.23, P<0.001). Median daily maternal consumption of PRF was 286 mg per day and decreased after orientation to 0 mg per day, P<0.001. In the control group, with GA of 32±4 w (29-37 w), there was no significant differences in median daily maternal consumption of PRF, mean ductal systolic velocitiy, diastolic velocity, PI and right ventricular to left ventricular diameter ratio (RV/LV) ratio.

CONCLUSION

Reduction of maternal PRF intake during pregnancy, especially in the third trimester, is followed by complete reversal of DC (wide open DA), which may influence maternal dietary habits in late pregnancy.

Idiopathic constriction of the fetal ductus arteriosus: three cases and review of the literature

Premature constriction or closure of the ductus arteriosus can occur during fetal life. It is a rare phenomenon and has been described secondary to medication or structural lesions or as idiopathic constriction. Premature closure of the ductus arteriosus can lead to progressive right heart dysfunction with tricuspid regurgitation, congestive heart failure, fetal hydrops, and intrauterine death. This series describes diagnosis of fetal ductus arteriosus constriction of unknown etiology in 3 cases, prenatal management, and outcomes. Constriction of the ductus arteriosus can be diagnosed prenatally with careful interrogation of the ductal arch using pulsed Doppler sonography and complete fetal echocardiography. Close monitoring is mandatory to rule out development of right heart failure and to determine the intervention time.