Antenatal exposure to sulindac and risk of necrotizing enterocolitis

Antenatal exposure to nonsteroidal anti-inflammatory drugs and risk of neonatal hypertension

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used as tocolytics, which are medications that suppress uterine contractions for preterm birth prevention. Their effect on cerebral/systemic vascular beds poses the question of whether antenatal NSAID exposure is associated with neonatal hypertension. We performed a retrospective case-control study in a tertiary neonatal intensive care unit, including 40 hypertension cases (hospitalized neonates ≥ 35 weeks with systolic BP > 100 mm Hg on three consecutive days) compared to 134 controls matched by gestational age at delivery, plurality, and delivery date. Cases and controls were compared by antenatal NSAID exposure, other common tocolytics, and maternal/neonatal characteristics and complications. Multivariable logistic regression was used to estimate the odds of hypertension among those with prenatal exposure to NSAIDs versus those without exposure. Newborns with hypertension had a lower gestational age at delivery and increased incidence of neonatal complications, including respiratory distress syndrome, bronchopulmonary dysplasia, surfactant administration, longer duration of ventilation, and history of umbilical artery catheterization. Days of indomethacin exposure were positively associated with greater odds of neonatal hypertension (OR 1.17 [1.00 to 1.38], P = 0.055), even after adjustment for other factors associated with neonatal hypertension. Newborns with hypertension were less likely to have been exposed to calcium channel blockers as a tocolytic. The results of our study suggest an association between prenatal exposure to nonsteroidal anti-inflammatory drugs and neonatal hypertension. Furthermore, our data suggest that prenatal calcium channel blocker exposure may protect against the development of neonatal hypertension. Future multicenter studies are needed to understand the risks of tocolytics and subsequent consequences in preterm infants.

Tocolytics used as adjunctive therapy at the time of cerclage placement: a systematic review

OBJECTIVE

To review the published literature on whether the use of empiric perioperative tocolytic medications could provide additional benefit when used in combination with cerclage.

STUDY DESIGN

Systematic review of published medical literature reporting the efficacy of empiric tocolytics used as a perioperative adjunct to vaginal cerclage in high-risk patients. A PubMed search without date criteria of various tocolytics and cerclage yielded 42 studies. Review articles were excluded, as were reports of abdominal cerclage, emergent cerclage, or cerclage for the purpose of delayed interval delivery in twin gestations.

RESULT

Only five publications on the topic of perioperative tocolytic use at the time of history or ultrasound-indicated vaginal cerclage placement were identified. These included zero clinical trials, three retrospective cohort studies, one case series and one case report. Only one cohort study compared cerclage with indomethacin and cerclage without indomethacin and suggested no difference between the groups. The other two published cohort studies had no referent group who received cerclage without tocolysis. One case series and one case report were also published reporting cerclage with empiric beta-mimetic and progesterone adjunctive therapy.

CONCLUSION

There is a paucity of published data on the topic of adjunctive perioperative tocolytics with cerclage. Adequately powered clinical trials on perioperative use of tocolysis with cerclage compared with a standard cerclage placement alone are needed to establish efficacy. Until adequately studied, this practice should be considered investigational.