Persistent anuria, neonatal death, and renal microcystic lesions after prenatal exposure to indomethacin

OBJECTIVE

The purpose of this study is to emphasize the high risk of renal failure and severe morphologic changes related to prolonged prenatal exposure to indomethacin.

STUDY DESIGN

Referred renal specimens from six anuric neonates exposed in utero to indomethacin were studied. Clinical charts were retrospectively reviewed. Indomethacin dosages varied from 150 to 400 mg daily, and the drug was given for a 2- to 11-week period, until birth.

RESULTS

All infants died in anuria, 4 of them after 7 to 39 days on peritoneal dialysis. In 5 infants cystic dilatations of superficial nephrons were associated with ischemic changes of the deep cortex. By immunohistochemical analysis intrarenal renin content was increased in 4 of 5 patients.

CONCLUSION

Long-term indomethacin treatment during pregnancy may lead to the development of renal failure and irreversible renal damage with cystic dilatation of developing nephrons in an exposed fetus. Prior stimulation of the renin-angiotensin system may favor this complication.

[Maternal and neonatal effects of indomethacin administrated during pregnancy. Apropos of 18 cases]

BACKGROUND

There have been several reports that prolonged exposure of pregnant women to indomethacin for tocolysis may have significant pharmacological effects on the fetus or newborn.

PATIENTS

Eighteen pregnant women were given indomethacin during the year 1989 for treatment of premature labor (n = 16) or polyhydramnios (n = 2). Treatment was started at gestational week 28.1 +/- 2.5 and was discontinued at gestational week 30.7 +/- 1.8. The mean age of the women at the onset of pregnancy was 30.6 +/- 5.3 years. The daily dose of indomethacin was initially 200 mg (2-3 mg/kg), then 107 +/- 59 mg. The cumulative dose was 1,820 +/- 2,370 mg. The duration of treatment was 18.1 +/- 16.4 days (less than 7 days in 8 women).

RESULTS

The term at delivery was 33.4 +/- 3.3 weeks (11 after 32 weeks). The mean interval between discontinuation of treatment and delivery was 19.0 +/- 18.7 days. Indomethacin was effective in 10 cases of premature labor, and gestation was prolonged by 52.6 +/- 19.2 days. Among the 23 live-born neonates, 5 developed renal insufficiency attributed to indomethacin (4 premature labor, 1 hydramnios). The kidney failure with early hyperkalemia was cured within about 7 days in 4 cases. The remaining neonate also suffered from severe prolonged hypoxia and died on day 4.

CONCLUSIONS

Administration of indomethacin for premature labor places the fetus at risk because of the short drug-free interval before birth. High daily or cumulative doses of indomethacin dit not result in adverse effects.

[Fetal toxicity of non-steroidal anti-inflammatory agents]

All non-steroidal anti-inflammatory drugs (NSAIDs) are prostaglandin inhibitors, which explains their foetal toxicity. So far, no epidemiological study of their cardiopulmonary and renal effects has been carried out, but case-reports have been published. The cardiopulmonary effects of NSAIDs include closure of the ductus arteriosus, pulmonary hypertension cardiopathy and tricuspid valve insufficiency. They were responsible for 31 neonatal accidents, 8 of which were fatal (for 22 pregnant women, 7 bearing twins, 1 bearing triplets). The renal effects of NSAIDs consisted of acute renal failure with oedema, oliguria, hyponatraemia and marked hyperkalaemia. They affected 23 neonates, 8 of whom died (for 17 pregnant women, 4 bearing twins, 1 bearing triplets). A few epidemiological studies have reported foetal haemorrhages when aspirin was used by the mother as anti-inflammatory agent. In comparative trials of indomethacin as short treatment of premature labour and polyhydramnios the drug proved to be effective. In obstetrical tocolysis NSAIDs can be given in the absence of alternative therapy with beta-adrenergic agents, and their risk can be minimized by ultrasonographic examination and monitoring of foetal cardiac function and diuresis. In the field of rheumatology, corticosteroids would be a good alternative to NSAIDs for rheumatic diseases, but using NSAIDs for low back pain, sciatica, haemorrhoids, toothaches, sinusitis, etc., would not be justified in pregnant women. Self medication must be discouraged.

Characteristics of medication errors in pediatrics

A six-month prospective study was carried out by 16 poison control centers in France to assess the epidemiology of medication errors in pediatrics. In this study, 1108 medication errors were analyzed. Mean population age was 3.2 years (median 2 years, range 3 days-15 years), and 30 percent of the children were under 1 year of age. The most frequent error characteristics were family responsibility, 87 percent (a member of the patient's family most often committed the error in medication use); parental prescribing decision, 31.5 percent (medication administered to the child by the parents without medical consultation or the advice of a pharmacist); incorrect execution of the prescription by the parents, 30 percent (error in dispensing, route of administration, etc.); oral forms, 52 percent (errors occurred most frequently with oral as opposed to other forms); incorrect dosage, 31.5 percent; and drug error, 30 percent (the drug dispensed was not the one prescribed). Iatrogenic injury occurred in 186 patients (17 percent) and 161 were hospitalized (15 percent). The majority of these were for surveillance only. The clinical outcome caused by medication error was unfavorable in two cases. The types of drugs most frequently misused included morphinic cough suppressants (9.5 percent), salicylates (9.1 percent), and ear, nose, and throat drops (9 percent); 459 proprietary medicines were specified. Prevention of medication errors should involve certain main requirements: formulations and package instructions specific to pediatric patients to ensure appropriateness and accuracy, detailed information given to patients by physicians and pharmacists about their prescriptions, and more public information concerning the risks of remedies or medication administered to children by parents who do not seek medical advice.

[QT prolongation and circulatory arrest after an injection of erythromycin in a newborn infant]

A 8 day-old full-term newborn showed severe cardiac disturbances after intravenous injection of erythromycin. The neonate, suspected of having Chlamydia pneumonitis because of tachypnea and rhinitis, had been given 5 injections of erythromycin without clinical effect. Pallor, vomiting and bradycardia developed a few minutes after the 6th injection, and ECG showed ventricular arrhythmia, prolonged QT interval and an atrioventricular block. The infant died in intensive care unit. This case and the analysis of other published cases of cardiac disturbances following the parenteral use of erythromycin, indicate the potential arrhythmogenic risk of this drug. It is suggested that newborns treated with erythromycin should be monitored by ECG.

[Corneal toxicity of cytarabine. Apropos of a case]

A 4 1/2 year old girl with acute lymphoblastic leukemia developed corneal toxicity while receiving courses of chemotherapy once a month (standard doses of vincristine, cyclophosphamide or teniposide, always associated with cytarabine and asparaginase). Symptoms began after 18 courses of treatment and consisted of ocular pain, foreign body sensation, blurred vision, bilateral conjunctival hyperemia. The symptoms appeared during the course of chemotherapy and decreased before the following course. Symptomatic treatment appeared to be effective. Ocular toxicity of antineoplastic agents and particularly cytarabine is discussed.

[Psychotropics and pregnancy. Apropos of 2 case reports: the dose of triazolam]

In this paper the authors report on two term-birth newborn infants who were exposed to long-term maternal treatment with benzodiazepines. They emphasize the free interval before the onset of respiratory pauses in these newborns, since triazolam is classified as belonging to the class of benzodiazepines with ultra-rapid elimination and especially the severity of these disorders.

[Immunoallergic tubulo-interstitial nephritis following ingestion of carbamazepine]

One month after taking carbamazepine for pain relief, a 13 year-old child with Friedrich's ataxia presented with an allergic rash and digestive and cardiac symptoms. Two weeks later, non-oliguric renal failure suggestive of interstitial nephritis was present. Acute renal failure resolved with pulse methyl prednisolone injections relayed with prednisone orally, for 2 months. Allergic manifestations with carbamazepine should lead to immediate withdrawal of treatment.