Premature closure of the ductus arteriosus

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 whichwas NSAIDs. Right ventricular hypertrophy was the most frequent sign during prenatal ultrasound [2] and approximately one-third of fetuseswere stillborn [3]. Among the livenewborns, 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 fromdiseasewithin 3 weeks of delivery. Appropriatemedication during pregnancy may prevent stillbirth and postnatal complications.