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Rutledge AD, Wahlquist AE, Patel EU, Hlavacek AM, Ryan RM, Steflik HJ. Patent Ductus Arteriosus Response to Treatment by Course and Associations with Perinatal and Clinical Factors. Am J Perinatol 2024; 41:e1759-e1768. [PMID: 37201531 DOI: 10.1055/s-0043-1768962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVE The objective of this study is to examine patent ductus arteriosus (PDA) response by treatment course and investigate associations with postmenstrual age (PMA), chronological age (CA), gestational age (GA), antenatal steroid exposure (ANS), birthweight (BW), weight at treatment initiation (WT), and PDA/left pulmonary artery (LPA) ratio. STUDY DESIGN This is a single-center retrospective cohort study of preterm infants less than 37 weeks' GA born January 1, 2016 to December 31, 2018 who received acetaminophen and/or indomethacin for PDA treatment. Cox proportional hazards regression models were used to determine whether factors of interest were associated with PDA response to medical treatment. RESULTS In total, 289 treatment courses were administered to 132 infants. Thirty-one (23%) infants experienced treatment-associated PDA closure. Ninety-four (71%) infants had evidence of PDA constriction following any treatment course. Ultimately, 84 (64%) infants experienced definitive PDA closure. For each 7-day increase in CA at the time of treatment initiation, the PDA was 59% less likely to close (p = 0.04) and 42% less likely to respond (i.e., constrict or close) to treatment (p < 0.01). PDA/LPA ratio was associated with treatment-associated PDA closure (p = 0.01). For every 0.1 increase in the PDA/LPA ratio, the PDA was 19% less likely to close in response to treatment. CONCLUSION In this cohort, PDA closure is independent of PMA, GA, ANS, BW, and WT; however, CA at treatment initiation predicted both treatment-associated PDA closure and PDA response (i.e., constriction or closure), and PDA/LPA ratio was associated with treatment-associated closure. Most infants experienced PDA constriction rather than closure, despite receiving up to four treatment courses. KEY POINTS · Detailed PDA responses for up to four treatment courses provide a novel perspective.. · Chronological age at the start of treatment predicted treatment-associated PDA closure and response.. · For each 7-day increase in chronological age, the PDA was 59% less likely to close..
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Affiliation(s)
- Austin D Rutledge
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Amy E Wahlquist
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
- Department of Biostatistics and Epidemiology, Center for Rural Health Research, East Tennessee State University, Johnson City, Tennessee
| | - Ekta U Patel
- Department of Pediatrics (Neonatology), Children's Mercy Hospital, Kansas City, Missouri
| | - Anthony M Hlavacek
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Rita M Ryan
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
- Department of Pediatrics (Neonatology), Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Heidi J Steflik
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
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Goel M, Dutta S, Saini SS, Sundaram V. Relationship between Decrease in Urine Output following Treatment with Prostaglandin Inhibitors and PDA Closure. Am J Perinatol 2024; 41:e53-e59. [PMID: 35436800 DOI: 10.1055/a-1827-7674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Prostaglandin inhibitors are used for the treatment of patent ductus arteriosus (PDA) and they often transiently decrease the urine output (UO) due to prostaglandin inhibition in the renal vasculature. We hypothesized that preterm infants whose renal vasculature shows greater sensitivity to prostaglandin inhibitors are likely to have ductal tissue with greater sensitivity to the same. Our objective was to determine whether the decrease in UO following treatment of PDA with a prostaglandin inhibitor is associated with a higher probability of PDA closure. STUDY DESIGN In a prospective, proof-of-concept, cohort study, we enrolled 40 preterm neonates with hemodynamically significant PDA (hsPDA), being treated with a prostaglandin inhibitor. The key predictor, UO, was measured at baseline and daily until 72 hours. We repeated echocardiography daily until PDA closure or the end of treatment. The key outcome was PDA closure. We compared "PDA-closed" (n = 28) and "PDA-open" (n = 12) groups for change in UO from baseline. RESULTS The median (Q1, Q3) percent decrease in UO (figures rounded off to integers) was greater in the "PDA-closed" versus "PDA-open" group: from baseline to 0 to 24 hours [-45% (-55%, +0.04%) vs. -15% (-28%, +49%)]; baseline to 24 to 48 hours [-41% (-53%, +14%) vs. -3% (-25%, +62%), p = 0.03] and baseline to 48 to 72 hours [-33% (-49%, +32%) vs. +21% (-7%, +98%), p = 0.02]. Decrease in UO preceded PDA closure. The "PDA-closed" group had significantly greater weight loss, despite a greater decrease in UO. A decrease in UO of 27 and 17% by 24 to 48 hours and 48 to 72 hours, respectively, best predicted PDA closure. CONCLUSION A decrease in UO after treating hsPDA with a prostaglandin inhibitor is associated with successful closure of PDA. KEY POINTS · Prostaglandin inhibition causes both decrease in urine output and PDA closure following medical treatment. · The association between drug-induced decrease in urine output and PDA closure has been inadequately studied.. · Decrease in urine output after treatment with prostaglandin inhibitors increases the chances of PDA closure..
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Affiliation(s)
- Malika Goel
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sourabh Dutta
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shiv Sajan Saini
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Venkataseshan Sundaram
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Hsieh YC, Jeng MJ, Lin MC, Lin YJ, Rohsiswatmo R, Dewi R, Chee SC, Neoh SH, Velasco BAE, Imperial MLS, Nuntnarumit P, Ngerncham S, Chang YS, Kim SY, Quek BH, Amin Z, Kusuda S, Miyake F, Isayama T. Contemporary fluid management, humidity, and patent ductus arteriosus management strategy for premature infants among 336 hospitals in Asia. Front Pediatr 2024; 12:1336299. [PMID: 38487471 PMCID: PMC10937448 DOI: 10.3389/fped.2024.1336299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/01/2024] [Indexed: 03/17/2024] Open
Abstract
Objectives The management of patent ductus arteriosus (PDA) is a critical concern in premature infants, and different hospitals may have varying treatment policies, fluid management strategies, and incubator humidity. The Asian Neonatal Network Collaboration (AsianNeo) collected data on prematurity care details from hospitals across Asian countries. The aim of this study was to provide a survey of the current practices in the management of PDA in premature infants in Asian countries. Methods AsianNeo performed a cross-sectional international questionnaire survey in 2022 to assess the human and physical resources of hospitals and clinical management of very preterm infants. The survey covered various aspects of hospitals resources and clinical management, and data were collected from 337 hospitals across Asia. The data collected were used to compare hospitals resources and clinical management of preterm infants between areas and economic status. Results The policy of PDA management for preterm infants varied across Asian countries in AsianNeo. Hospitals in Northeast Asia were more likely to perform PDA ligation (p < 0.001) than hospitals in Southeast Asia. Hospitals in Northeast Asia had stricter fluid restrictions in the first 24 h after birth for infants born at <29 weeks gestation (p < 0.001) and on day 14 after birth for infants born at <29 weeks gestation (p < 0.001) compared to hospitals in Southeast Asia. Hospitals in Northeast Asia also had a more humidified environment for infants born between 24 weeks gestation and 25 weeks gestation in the first 72 h after birth (p < 0.001). A logistic regression model predicted that hospitals were more likely to perform PDA ligation for PDA when the hospitals had a stricter fluid planning on day 14 after birth [Odds ratio (OR) of 1.70, p = 0.048], more incubator humidity settings (<80% vs. 80%-89%, OR of 3.35, p = 0.012 and <80% vs. 90%-100%, OR of 5.31, p < 0.001). Conclusions In advanced economies and Northeast Asia, neonatologists tend to adopt a more conservative approach towards fluid management, maintain higher incubator humidity settings and inclined to perform surgical ligation for PDA.
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Affiliation(s)
- Yao-Chi Hsieh
- Children’s Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Mei-Jy Jeng
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pediatrics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Chih Lin
- Children’s Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Pediatrics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Food and Nutrition, Providence University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Yuh-Jyh Lin
- Department of Pediatrics, National Cheng-Kung University Hospital, Tainan, Taiwan
| | - Rinawati Rohsiswatmo
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Rizalya Dewi
- Budhi Mulia Women and Children Hospital, Pekanbaru, Indonesia
| | - Seok Chiong Chee
- School of Medicine, Faculty of Health and Medical Sciences, Taylor’s University, Subang Jaya, Malaysia
| | - Siew Hong Neoh
- School of Medicine, Faculty of Health and Medical Sciences, Taylor’s University, Subang Jaya, Malaysia
| | | | | | - Pracha Nuntnarumit
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sopapan Ngerncham
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sae Yun Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bin Huey Quek
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Zubair Amin
- Department of Neonatology, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Satoshi Kusuda
- Neonatal Research Network of Japan, Tokyo, Japan
- Department of Pediatrics, Kyorin University, Mitaka, Tokyo, Japan
| | - Fuyu Miyake
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Tetsuya Isayama
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
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Jackson CD, Capino AC, Stuart LH, Wagner JL. Evaluation of the Closure of Patent Ductus Arteriosus With Ibuprofen Compared to Indomethacin. J Pediatr Pharmacol Ther 2023; 28:618-627. [PMID: 38025150 PMCID: PMC10681078 DOI: 10.5863/1551-6776-28.7.618] [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: 08/28/2022] [Accepted: 11/23/2022] [Indexed: 12/01/2023]
Abstract
OBJECTIVE Limited data exist comparing indomethacin and ibuprofen for the treatment of patent ductus arteriosus (PDA). The objective was to compare the safety and efficacy of indomethacin and ibuprofen for treatment of PDA closure. METHODS This single-center, pre-test/post-test quasi-experiment included preterm infants admitted to the neonatal intensive care unit who received indomethacin (July 1, 2013-September 30, 2015) or ibuprofen (December 1, 2015-July 31, 2019) for PDA. Patients were excluded if they were thrombocytopenic, had existing kidney injury, unresolved intraventricular hemorrhage (IVH) or necrotizing enterocolitis (NEC) at treatment initiation. Data were obtained from the electronic health record. Study outcomes were complete PDA closure, degree of PDA closure, resolution of symptoms, and new-onset acute kidney injury (AKI), IVH, or NEC. RESULTS A total of 114 patients were included: 44 (39%) received indomethacin and 70 (61%) received -ibuprofen. Twenty-one (21%) patients experienced successful PDA closure within 1 week: 13 (32%) indomethacin patients and 8 (13%) ibuprofen patients (p = 0.023). PDA size reduction occurred in 43 (46%) patients with 29 (25%) experiencing complete symptom resolution. Significantly more indomethacin patients compared with ibuprofen patients experienced new-onset AKI (48% vs 17%; p < 0.001) and received concomitant nephrotoxins (68% vs 39%; p = 0.002). There were no significant differences in new-onset IVH or NEC. CONCLUSIONS Indomethacin administration successfully closed the PDA in more neonates than ibuprofen but resulted in higher rates of AKI. However, this was confounded by more frequent administration of concomitant nephrotoxins. Larger trials are needed to help elucidate the optimal drug for closure of the PDA in neonates.
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Affiliation(s)
- Cory D. Jackson
- Department of Pharmacy (CJ), Jefferson Regional Medical Center, Pine Bluff, AR
| | - Amanda C. Capino
- Department of Pharmacy Practice (AC), University of Mississippi School of Pharmacy, Jackson, MS
| | - Lindsay H. Stuart
- Department of Pediatric Pharmacy (LS), University of Mississippi Medical Center, Jackson, MS
| | - Jamie L. Wagner
- Department of Pharmacy Practice (JW), University of Mississippi School of Pharmacy, Jackson, MS
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Carneiro L, Bouissou A, Favrais G. Increasing the dose of ibuprofen with postnatal age to close a hemodynamically significant patent ductus arteriosus in very preterm infants. Eur J Pediatr 2023; 182:3527-3535. [PMID: 37204599 DOI: 10.1007/s00431-023-04986-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 05/20/2023]
Abstract
Patent ductus arteriosus (PDA) is associated with neonatal morbidities in high-risk preterm infants. Early neonatal treatment by ibuprofen induces the ductus arteriosus (DA) closure in approximatively 60% of infants. Dose escalation of ibuprofen according to postnatal age has been suggested for improving the DA closure rate. The aim of this study was to assess the efficacy and tolerance of an increasing dose regimen of ibuprofen. This single-center retrospective cohort study involved infants hospitalized from 2014 to 2019 in our neonatal unit. Selection criteria were gestational age < 30 weeks, birth weight < 1000 g, and treatment by ibuprofen. Three dose levels were used and consisted of a daily intravenous injection of ibuprofen-tris-hydroxymethyl-aminomethane (ibuprofen-THAM) for three consecutive days: (i) 10 -5 -5 mg/kg before the 70th h of life (H70) (dose level 1), (ii) 14 -7 -7 mg/kg between H70 and H108 (dose level 2), (iii) 18 -9 -9 mg/kg after H108 (dose level 3). The ibuprofen-induced DA closure was compared between ibuprofen schedules, and the Cox proportional-hazard regression was performed to identify factors associated with the ibuprofen efficacy. Tolerance was assessed through renal function, acidosis, and platelet count. One hundred forty-three infants met the inclusion criteria. The ibuprofen-induced DA closure was observed in 67 infants (46.8%). One course of ibuprofen at dose level 1 was more efficient in closing the DA than other schedules (dose level 1, one course (n = 70): 71%, dose level 2 or 3, one course (n = 20): 45%, two-course schedules (n = 53): 15%, p < 0.0001). Independent factors associated with ibuprofen-induced DA closure were a complete antenatal schedule of steroids (p = 0.001), a lower CRIB II score (p = 0.009), and a lower and earlier exposure to ibuprofen (p < 0.0001 and p = 0.002). No severe side effects were observed. Neonatal mortality and morbidities were similar regardless of the infant's response to ibuprofen. Conclusion: Increasing ibuprofen doses with postnatal age failed to reach an efficacy similar to earlier treatment. Although the infant response to ibuprofen was likely to depend on multiple factors, the optimal use of ibuprofen included its early initiation. What is Known: • Ibuprofen is the current first-line treatment for patent ductus arteriosus during the early neonatal period in very preterm infants. • However, the ibuprofen efficacy rapidly declined with postnatal age during the first week of life. A dose escalation of ibuprofen according to postnatal age has been suggested to improve the ibuprofen-induced ductus arteriosus closure. What is New: • The rapid drop of ibuprofen's ability to close hemodynamically significant patent ductus arteriosus persisted beyond the postnatal day 2 despite the dose adjustment arguing for an early initiation to optimize its efficacy. • The early selection of patients who will suffer from patent ductus arteriosus-related morbidities and who will positively respond to ibuprofen is an issue that could determine the future place of ibuprofen in the patent ductus arteriosus management.
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Affiliation(s)
| | | | - Geraldine Favrais
- Neonatology Department, CHU de Caen Normandie, 14000, Caen, France.
- INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron Institut Blood and Brain @ Caen-Normandie (BB@C), Normandie University, UNICAEN, 14000, Caen, France.
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Villamor E, Borges-Luján M, González-Luis G. Association of patent ductus arteriosus with fetal factors and endotypes of prematurity. Semin Perinatol 2023; 47:151717. [PMID: 36914506 DOI: 10.1016/j.semperi.2023.151717] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
During fetal life, the ductus arteriosus (DA) acquires the mechanisms for its postnatal closure following a thorough developmental program. This program can be interrupted by preterm birth and is also susceptible to alteration during fetal life by numerous physiological and pathological stimuli. In this review, we aim to summarize the evidence on how physiological and pathological factors affect DA development, eventually leading to patent DA (PDA). Specifically, we reviewed the associations of sex, race, and pathophysiological pathways leading to very preterm birth (endotypes) with PDA incidence and pharmacological closure. Summary of evidence suggests that there are no male-female differences in the incidence of PDA among very preterm infants. In contrast, risk of developing PDA appears to be higher in infants exposed to chorioamnionitis or who are small for gestational age. Finally, hypertensive disorders of pregnancy may be associated with a better response to pharmacological treatment of PDA. All of this evidence comes from observational studies and therefore associations do not imply causation. The current trend for many neonatologists is to wait for the natural evolution of preterm PDA. Continued research is needed to identify which fetal and perinatal factors modulate the eventual late closure of PDA in very and extremely preterm infants.
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Affiliation(s)
- Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Centre (MUMC+), School for Oncology and Reproduction (GROW), University of Maastricht, P. Debyelaan 25. P.O. Box 5800, Maastricht, AZ 6202, the Netherlands.
| | - Moreyba Borges-Luján
- Department of Neonatology, Complejo Hospitalario Universitario Insular Materno-Infantil (CHUIMI) de Canarias, Las Palmas de Gran Canaria, Spain
| | - Gema González-Luis
- Department of Neonatology, Complejo Hospitalario Universitario Insular Materno-Infantil (CHUIMI) de Canarias, Las Palmas de Gran Canaria, Spain
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Interactions between PDA-associated polymorphisms and genetic ancestry alter ductus arteriosus gene expression. Pediatr Res 2022; 91:903-911. [PMID: 33837257 PMCID: PMC8501158 DOI: 10.1038/s41390-021-01506-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND DNA polymorphisms in PTGIS and TFAP2B have been identified as risk factors for patent ductus arteriosus (PDA) in a population composed of preterm infants with European genetic ancestry but not in more genetically diverse populations. GOAL To determine if the effects of TFAP2B and PTGIS polymorphisms on ductus arteriosus (DA) gene expression differ based on genetic ancestry. METHODS DA from 273 human second trimester fetuses were genotyped for TFAP2B and PTGIS polymorphisms and for polymorphisms distributing along genetic ancestry lines. RT-PCR was used to measure the RNA expression of 49 candidate genes involved with DA closure. RESULTS Seventeen percent of the DA analyzed were of European ancestry. In multivariable regression analyses we found consistent associations between four PDA-related TFAP2B polymorphisms (rs2817399(A), rs987237(G), rs760900(C), and rs2817416(C)) and expression of the following genes: EPAS1, CACNB2, ECE1, KCNA2, ATP2A3, EDNRA, EDNRB, BMP9, and BMP10, and between the PTGIS haplotype rs493694(G)/rs693649(A) and PTGIS and NOS3. These changes only occurred in DA with European ancestry. No consistent positive or negative associations were found among DA samples unless an interaction between the polymorphisms and genetic ancestry was taken into account. CONCLUSION PTGIS and TFAP2B polymorphisms were associated with consistent changes in DA gene expression when present in fetuses with European ancestry. IMPACT DNA polymorphisms in PTGIS and TFAP2B have been identified as risk factors for patent ductus arteriosus (PDA) in a population composed primarily of preterm infants with European genetic ancestry but not in more genetically diverse populations. The same PTGIS and TFAP2B polymorphisms are associated with changes in ductus gene expression when present in ductus from fetuses with European genetic ancestry. No consistent associations with gene expression can be found unless an interaction between the polymorphisms and genetic ancestry is taken into account.
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Boldt R, Mäkelä PM, Immeli L, Sund R, Leskinen M, Luukkainen P, Andersson S. Blood pressure changes during the first 24 hours of life and the association with the persistence of a patent ductus arteriosus and occurrence of intraventricular haemorrhage. PLoS One 2021; 16:e0260377. [PMID: 34847157 PMCID: PMC8631614 DOI: 10.1371/journal.pone.0260377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 11/08/2021] [Indexed: 11/18/2022] Open
Abstract
Very low birthweight (VLBW) infants are at risk of intraventricular haemorrhage (IVH) and delayed closure of ductus arteriosus. We investigated mean arterially recorded blood pressure (MAP) changes during the first day of life in VLBW infants as potential risk factors for a patent ductus arteriosus (PDA) and IVH. This retrospective cohort study exploring MAP changes during adaption and risk factors for a PDA and IVH comprised 844 VLBW infants admitted to the Helsinki University Children’s Hospital during 2005–2013. For each infant, we investigated 600 time-points of MAP recorded 4–24 hours after birth. Based on blood pressure patterns revealed by a data-driven method, we divided the infants into two groups. Group 1 (n = 327, mean birthweight = 1019 g, mean gestational age = 28 + 1/7 weeks) consisted of infants whose mean MAP was lower at 18–24 hours than at 4–10 hours after birth. Group 2 (n = 517, mean birthweight = 1070 g, mean gestational age = 28 + 5/7 weeks) included infants with a higher mean MAP at 18–24 hours than at 4–10 hours after birth. We used the group assignments, MAP, gestational age at birth, relative size for gestational age, surfactant administration, inotrope usage, invasive ventilation, presence of respiratory distress syndrome or sepsis, fluid intake, and administration of antenatal steroids to predict the occurrence of IVH and use of pharmacological or surgical therapy for a PDA before 42 weeks of gestational age. Infants whose mean MAP is lower at 18–24 hours than at 4–10 hours after birth are more likely to undergo surgical ligation of a PDA (odds ratio = 2.1; CI 1.14–3.89; p = 0.018) and to suffer from IVH (odds ratio = 1.83; CI 1.23–2.72; p = 0.003).
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Affiliation(s)
- Robert Boldt
- New Children’s Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
- * E-mail:
| | - Pauliina M. Mäkelä
- New Children’s Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Lotta Immeli
- New Children’s Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Reijo Sund
- University of Eastern Finland, School of Medicine, Kuopio, Finland
| | - Markus Leskinen
- New Children’s Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Päivi Luukkainen
- New Children’s Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Sture Andersson
- New Children’s Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
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Vaidya R, Knee A, Paris Y, Singh R. Predictors of successful patent ductus arteriosus closure with acetaminophen in preterm infants. J Perinatol 2021; 41:998-1006. [PMID: 32879417 PMCID: PMC7463098 DOI: 10.1038/s41372-020-00803-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/28/2020] [Accepted: 08/25/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Evaluate predictors of successful PDA closure following acetaminophen treatment. STUDY DESIGN Retrospective cohort study of ≤30 weeks GA infants born from 1 January 2013-30 September 2019, and treated with single course acetaminophen by symptomatic PDA treatment strategy. Multiple maternal and neonatal variables were identified as potential predictors. Univariate analysis and multivariable regression models were applied to evaluate the strongest predictors. RESULTS Sixty-six patients were included, 28 (42.4%) had successful PDA closure following acetaminophen. Success was associated with GA > 26 weeks (65% vs. 33%, AUC = 0.64), birthweight >750 g (53% vs. 32%, AUC = 0.61), PDA size ≤0.2 cm (63% vs. 32%, AUC = 0.64), and no prior indomethacin use (56% vs. 33%, AUC = 0.61). Multivariable model identified GA > 26 weeks (RR = 1.92, CI 1.20-3.09) and PDA size ≤0.2 cm (RR: 1.82, CI 1.11-2.98) as the strongest predictors. CONCLUSION Acetaminophen may be more successful in targeted PDA closure in >26 weeks GA infants with PDA size ≤0.2 cm.
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Affiliation(s)
- Ruben Vaidya
- Division of Newborn Medicine, Department of Pediatrics, University of Massachusetts Medical School - Baystate, Springfield, MA, 01199, USA.
| | - Alexander Knee
- grid.266683.f0000 0001 2184 9220Epidemiology and Biostatistics Research Core, Office of Research, Baystate Medical Center, University of Massachusetts Medical School - Baystate, Springfield, MA 01199 USA ,grid.266683.f0000 0001 2184 9220Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA 01199 USA
| | - Yvonne Paris
- grid.266683.f0000 0001 2184 9220Division of Pediatric Cardiology, Department of Pediatrics, University of Massachusetts Medical School - Baystate, Springfield, MA 01199 USA
| | - Rachana Singh
- grid.266683.f0000 0001 2184 9220Division of Newborn Medicine, Department of Pediatrics, University of Massachusetts Medical School - Baystate, Springfield, MA 01199 USA
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Lee JA, Sohn JA, Oh S, Choi BM. Perinatal risk factors of symptomatic preterm patent ductus arteriosus and secondary ligation. Pediatr Neonatol 2020; 61:439-446. [PMID: 32362475 DOI: 10.1016/j.pedneo.2020.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 03/03/2020] [Accepted: 03/31/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND There has been conflicting evidence for the association between antenatal factors and the development of symptomatic patent ductus arteriosus (PDA) or failure of pharmacologic treatment, especially for maternal pregnancy-induced hypertension (PIH) or chorioamnionitis. We assessed the perinatal risk factors of symptomatic PDA in preterm infants and those of secondary ligation in infants with pharmacologic treatment for symptomatic PDA using a national cohort. METHODS A total of 2961 infants with 22-29 weeks of gestation with symptomatic PDA or no PDA were included from the Korean Neonatal Network database. To identify significant perinatal risk factors associated with symptomatic PDA or secondary ligation, all perinatal factors were included in the univariate and multivariate generalized estimating equation analysis and final model was selected using backward elimination method based on Quasi-likelihood Information Criterion. RESULTS Lower gestational age (GA), female gender, maternal PIH and surfactant use were significant risk factors of symptomatic PDA. Antenatal corticosteroid use decreased the risk of symptomatic PDA. For secondary ligation, lower GA and cesarean section were significant risk factors. Adjusted odds ratio (aOR) of PIH as a risk factor of symptomatic PDA was 1.56 [95% confidence interval 1.17-2.08]. In the subgroup analysis according to the GA, lower GA, female gender, multiple pregnancy, maternal PIH and surfactant use increased the risk of symptomatic PDA, and histologic chorioamnionitis and antenatal corticosteroid use decreased the risk of symptomatic PDA only in GA 26-29 weeks group. CONCLUSION Lower GA increased the risk of symptomatic PDA and secondary ligation. Maternal PIH and surfactant use increased the risk of symptomatic PDA; however, antenatal corticosteroid use decreased it. Close observation of the clinical symptoms of PDA is needed in preterm infants with maternal PIH.
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Affiliation(s)
- Jin A Lee
- Department of Pediatrics, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea; Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea.
| | - Jin A Sohn
- Department of Pediatrics, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea; Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Sohee Oh
- Department of Biostatistics, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Byung Min Choi
- Department of Pediatrics, Korea Ansan Hospital, Gyunggi-do, South Korea; Department of Pediatrics, Korea University College of Medicine, Seoul, South Korea
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11
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Kimani S, Surak A, Miller M, Bhattacharya S. Use of combination therapy with acetaminophen and ibuprofen for closure of the patent ductus arteriosus in preterm neonates. Paediatr Child Health 2020; 26:e177-e183. [PMID: 34131462 DOI: 10.1093/pch/pxaa057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
Objective To compare effectiveness and safety of combination therapy (acetaminophen and ibuprofen) to monotherapy (ibuprofen, indomethacin, or acetaminophen alone) in treatment of the patent ductus arteriosus (PDA) in premature neonates. Methods This was a retrospective cohort study of neonates admitted to a tertiary-level neonatal intensive care unit. Included neonates were born at <32 weeks gestation and received pharmacotherapy for PDA closure. Based on the primary therapy received, our cohort was divided into the following four groups: indomethacin alone, ibuprofen alone, acetaminophen alone, and ibuprofen and acetaminophen (in combination). Baseline characteristics, effectiveness, safety, neonatal mortality, and morbidities rates between these groups were compared. Results One hundred and forty neonates were analyzed; 17 received combination therapy, and 123 neonates received monotherapy: 22 (17.9%) ibuprofen, 29 (23.6%) acetaminophen, and 72 (58.5%) indomethacin. The PDA closure rates were 41.7% for indomethacin, 41.2% for combination therapy, 37.9% for acetaminophen, and 31.8% for ibuprofen (P=0.100). Rates of adverse effects were comparable between the groups. Conclusion The rate of ductal closure was not different between combination therapy and monotherapy. The study did not demonstrate any increased adverse effects in the combination group. Future well-designed prospective clinical trials are needed to guide clinical practice.
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Affiliation(s)
- Susan Kimani
- Department of Pediatrics, Western University, London, Ontario.,Children's hospital, London Health Sciences Centre, London, Ontario
| | - Aimann Surak
- Department of Pediatrics, Western University, London, Ontario.,Children's hospital, London Health Sciences Centre, London, Ontario
| | - Michael Miller
- Department of Pediatrics, Western University, London, Ontario.,Children's Health Research Institute, London, Ontario
| | - Soume Bhattacharya
- Department of Pediatrics, Western University, London, Ontario.,Children's hospital, London Health Sciences Centre, London, Ontario.,Children's Health Research Institute, London, Ontario
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12
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Mydam J, Rastogi A, Naheed ZJ. Base excess and hematocrit predict response to indomethacin in very low birth weight infants with patent ductus arteriosus. Ital J Pediatr 2019; 45:107. [PMID: 31439021 PMCID: PMC6704716 DOI: 10.1186/s13052-019-0706-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/12/2019] [Indexed: 11/10/2022] Open
Abstract
Background The treatment of patent ductus arteriosus (PDA) in very low birth weight (VLBW) infants remains a challenge. The ability to predict which infants will respond to indomethacin could spare some from the risks of unnecessary medications. Our objective was to determine if indicators of acid-base homeostasis could predict response to indomethacin treatment for ductal closure, and thus help guide treatment decisions. Methods We performed a retrospective analysis of medical records of VLBW (< 1500 g) neonates with hemodynamically significant PDA born at our institution between January 2009 and December 2012; all infants included in the study were treated with indomethacin for ductal closure within the first 2 weeks of life. We extracted data for a number of clinical variables including gestational age, birth weight, blood chemistries, surfactant use, hematocrit, and blood gas parameters. Our primary outcome measure was successful closure of PDA following the first round of indomethacin. Using variables that were significant on initial testing, we created multivariable regression models to determine the independent association of selected variables with indomethacin response. Results Of the 91 infants included in the study, 62 (68%) responded to the first course of indomethacin with successful ductal closure. Multivariable regression modeling revealed that both base excess and hematocrit were independently associated with indomethacin response; odds of PDA closure increased with increasing base excess (OR [odds ratio]: 1.81; 95% confidence interval [CI]: 1.36–2.60) and increasing hematocrit (OR: 1.21; 95% CI: 1.01–1.45). The optimal cutoff value for base excess was − 4.56, with a sensitivity of 96.8% (95% CI: 89–100) and specificity of 79.3% (95% CI: 60–92); optimal cutoff value for hematocrit was 40, with 69.4% sensitivity (95% CI: 56–80) and 65.5% specificity (95% CI: 46–82). Conclusions Base excess and hematocrit may be independent predictors of indomethacin response in VLBW infants with PDA. Low-cost and readily accessible, acid-base indicators such as base excess could help guide treatment decisions. Electronic supplementary material The online version of this article (10.1186/s13052-019-0706-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Janardhan Mydam
- Division of Neonatology, Department of Pediatrics, John H. Stroger, Jr. Hospital of Cook County, 1969 W Ogden Avenue, Chicago, IL, 60612, USA.
| | - Alok Rastogi
- Division of Neonatology, Department of Pediatrics, John H. Stroger, Jr. Hospital of Cook County, 1969 W Ogden Avenue, Chicago, IL, 60612, USA
| | - Zahra J Naheed
- Division of Pediatric Cardiology, Department of Pediatrics, John H. Stroger, Jr. Hospital of Cook County, 1969 W Ogden Avenue, Chicago, 60612, IL, USA
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13
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Rooney SR, Shelton EL, Aka I, Shaffer CM, Clyman RI, Dagle JM, Ryckman K, Lewis TR, Reese J, Van Driest SL, Kannankeril PJ. CYP2C9*2 is associated with indomethacin treatment failure for patent ductus arteriosus. Pharmacogenomics 2019; 20:939-946. [PMID: 31486736 PMCID: PMC6817966 DOI: 10.2217/pgs-2019-0079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/15/2019] [Indexed: 12/12/2022] Open
Abstract
Aims: To identify clinical andgenetic factors associated with indomethacin treatment failure in preterm neonates with patent ductus arteriosus (PDA). Patients & Methods: This is a multicenter cohort study of 144 preterm infants (22-32 weeks gestational age) at three centers who received at least one treatment course of indomethacin for PDA. Indomethacin failure was defined as requiring subsequent surgical intervention. Results: In multivariate analysis, gestational age (AOR 0.76, 95% CI 0.60-0.96), surfactant use (AOR 9.77, 95% CI 1.15-83.26), and CYP2C9*2 (AOR 3.74; 95% CI 1.34-10.44) were each associated with indomethacin failure. Conclusion: Age, surfactant use, and CYP2C9*2 influence indomethacin treatment outcome in preterm infants with PDA. This combination of clinical and genetic factors may facilitate targeted indomethacin use for PDA.
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Affiliation(s)
- Sydney R Rooney
- Vanderbilt University School of Medicine, UCSF, Nashville, TN 37232, USA
| | - Elaine L Shelton
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Ida Aka
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Christian M Shaffer
- Department of Medicine, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Ronald I Clyman
- Department of Pediatrics & Cardiovascular Research Center, University of California San Francisco, San Francisco, CA 94143, USA
| | - John M Dagle
- Department of Pediatrics, University of Iowa, Iowa City, UMKC, IA 52242, USA
| | - Kelli Ryckman
- Department of Epidemiology, University of Iowa, Iowa City, UMKC, IA 52242, USA
| | - Tamorah R Lewis
- Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO 64110, USA
| | - Jeff Reese
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
- Department of Medicine, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Prince J Kannankeril
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
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14
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Understanding the pathobiology in patent ductus arteriosus in prematurity-beyond prostaglandins and oxygen. Pediatr Res 2019; 86:28-38. [PMID: 30965358 DOI: 10.1038/s41390-019-0387-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/05/2019] [Accepted: 03/27/2019] [Indexed: 12/14/2022]
Abstract
The ductus arteriosus (DA) is probably the most intriguing vessel in postnatal hemodynamic transition. DA patency in utero is an active state, in which prostaglandin E2 (PGE2) and nitric monoxide (NO), play an important role. Since the DA gets programmed for postnatal closure as gestation advances, in preterm infants the DA frequently remains patent (PDA). PGE2 exposure programs functional postnatal closure by inducing gene expression of ion channels and phosphodiesterases and anatomical closure by inducing intimal thickening. Postnatally, oxygen inhibits potassium and activates calcium channels, which ultimately leads to a rise in intracellular calcium concentration consequently inducing phosphorylation of the myosin light chain and thereby vasoconstriction of the DA. Since ion channel expression is lower in preterm infants, oxygen induced functional vasoconstriction is attenuated in comparison with full term newborns. Furthermore, the preterm DA is more sensitive to both PGE2 and NO compared to the term DA pushing the balance toward less constriction. In this review we explain the physiology of DA patency in utero and subsequent postnatal functional closure. We will focus on the pathobiology of PDA in preterm infants and the (un)intended effect of antenatal exposure to medication on both fetal and neonatal DA vascular tone.
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15
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Hsu KH, Wu TW, Wu IH, Lai MY, Hsu SY, Huang HW, Mok TY, Lee CC, Lien R. Baseline cardiac output and its alterations during ibuprofen treatment for patent ductus arteriosus in preterm infants. BMC Pediatr 2019; 19:179. [PMID: 31167645 PMCID: PMC6549361 DOI: 10.1186/s12887-019-1560-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 05/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infants with hemodynamically significant patent ductus arteriosus (PDA) may physiologically compensate with a supranormal cardiac output (CO). As such, a supranormal CO may be a surrogate marker for a significant PDA or indicate a failed response to PDA closure by ibuprofen. Electrical cardiometry (EC) is an impedance-based monitor that can continuously and non-invasively assess CO (COEC). We aimed to trend COEC through ibuprofen treatment for PDA in preterm infants. METHODS We reviewed our database of preterm infants receiving ibuprofen for PDA closure. Response to ibuprofen was defined as no ductal flow in echocardiography ≤24 h after treatment. Responders were compared with gestational age (GA) and postnatal age matched non-responders and their trends of COEC were compared. Both groups' baseline COEC were further compared to the reference infants without PDA. RESULTS Eighteen infants (9 responders and 9 non-responders) with median (interquatile range) GA 27.5 (26.6-28.6) weeks, birthweight 1038 (854-1218) g and age 3.5 (3.0-4.0) days were studied. There were positive correlations between COEC and ductal diameter and left atrium/ aortic root ratio (r = 0.521 and 0.374, p < 0.001, respectively). Both responders and non-responders had significantly higher baseline COEC than the reference. Although there was no significant within-subject alteration of COEC during ibuprofen treatment, there was a between-subject difference indicating non-responders had generally higher COEC. CONCLUSIONS The changes of COEC during pharmacological closure of PDA is less drastic compared to surgical closure. Infants with PDA had higher baseline COEC compared to those without PDA, and non-responders had higher COEC especially at baseline compared to responders.
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Affiliation(s)
- Kai-Hsiang Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan. .,Graduate Institute of Clinical Medical Science, Chang Gung University, Taoyuan, Taiwan.
| | - Tai-Wei Wu
- Center for Fetal and Neonatal Medicine, Division of Neonatology, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - I-Hsyuan Wu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
| | - Mei-Yin Lai
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Science, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Yun Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan.,Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Keelung Branch, Keelung, Taiwan
| | - Hsiao-Wen Huang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
| | - Tze-Yee Mok
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
| | - Cheng-Chung Lee
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Science, Chang Gung University, Taoyuan, Taiwan
| | - Reyin Lien
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
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16
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Comparative effectiveness of drugs used to constrict the patent ductus arteriosus: a secondary analysis of the PDA-TOLERATE trial (NCT01958320). J Perinatol 2019; 39:599-607. [PMID: 30850756 PMCID: PMC6561645 DOI: 10.1038/s41372-019-0347-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/07/2019] [Accepted: 02/14/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of drugs used to constrict patent ductus arteriosus (PDA) in newborns < 28 weeks. METHODS We performed a secondary analysis of the multi-center PDA-TOLERATE trial (NCT01958320). Infants with moderate-to-large PDAs were randomized 1:1 at 8.1 ± 2.1 days to either Drug treatment (n = 104) or Conservative management (n = 98). Drug treatments were assigned by center rather than within center (acetaminophen: 5 centers, 27 infants; ibuprofen: 7 centers, 38 infants; indomethacin: 7 centers, 39 infants). RESULTS Indomethacin produced the greatest constriction (compared with spontaneous constriction during Conservative management): RR (95% CI) = 3.21 (2.05-5.01)), followed by ibuprofen = 2.03 (1.05-3.91), and acetaminophen = 1.33 (0.55-3.24). The initial rate of acetaminophen-induced constriction was 27%. Infants with persistent moderate-to-large PDA after acetaminophen were treated with indomethacin. The final rate of constriction after acetaminophen ± indomethacin was 60% (similar to the rate in infants receiving indomethacin-alone (62%)). CONCLUSION Indomethacin was more effective than acetaminophen in producing ductus constriction.
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17
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Pereira SS, Kempley ST, Shah DK, Morris JK, Sinha AK. Early echocardiography does not predict subsequent treatment of symptomatic patent ductus arteriosus in extremely preterm infants. Acta Paediatr 2018; 107:1909-1916. [PMID: 29663524 DOI: 10.1111/apa.14361] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 04/03/2018] [Accepted: 04/09/2018] [Indexed: 11/30/2022]
Abstract
AIM To determine whether early echocardiographic ductal parameters identified infants who subsequently received medical or surgical treatment of the patent ductus arteriosus (PDA). METHODS Infants <29 weeks had PDA size in 2D and colour, flow velocity and patterns obtained on days 1 and 3. Infants were followed up to identify those subsequently receiving treatment for symptomatic PDA by clinicians who were unaware of scan results. Receiver operator characteristics curves and logistic regression were performed. RESULTS Sixty infants were studied. Mean (SD) gestation and birthweight were 25.8 (1.5) weeks and 817 (190) grams, respectively. Twenty-four (40%) infants received medical treatment, and nine (15%) infants received surgical ligation of PDA at a median age of 12 and 37 days, respectively. PDA size on days 1 and 3, change in ductal size between days 1 and 3, flow pattern/velocity did not predict whether infants subsequently received medical or surgical management of PDA. Using logistic regression, gestation (p = 0.006) was the only factor that predicted whether infants would subsequently receive medical or surgical treatment for PDA in this cohort. CONCLUSION Echocardiographic ductal parameters on day 1 or 3 did not identify infants who received PDA treatment. Gestation was the most powerful predictor for receiving medical or surgical treatment of PDA.
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Affiliation(s)
- Sujith S. Pereira
- Neonatal Unit; Royal London Hospital; Barts Health NHS Trust; London UK
- Centre for Genomics and Child Health; Blizard Institute; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
| | - Stephen T. Kempley
- Neonatal Unit; Royal London Hospital; Barts Health NHS Trust; London UK
- Centre for Genomics and Child Health; Blizard Institute; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
| | - Divyen K. Shah
- Neonatal Unit; Royal London Hospital; Barts Health NHS Trust; London UK
- Centre for Genomics and Child Health; Blizard Institute; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
| | - Joan K. Morris
- Centre for Environmental and Preventive Medicine; Wolfson Institute of Preventive Medicine; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
| | - Ajay K. Sinha
- Neonatal Unit; Royal London Hospital; Barts Health NHS Trust; London UK
- Centre for Genomics and Child Health; Blizard Institute; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
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18
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Lewis TR, Shelton EL, Van Driest SL, Kannankeril PJ, Reese J. Genetics of the patent ductus arteriosus (PDA) and pharmacogenetics of PDA treatment. Semin Fetal Neonatal Med 2018; 23:232-238. [PMID: 29510900 PMCID: PMC6098727 DOI: 10.1016/j.siny.2018.02.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patent ductus arteriosus (PDA) is a frequent, complex, and difficult to treat clinical syndrome among preterm infants in the neonatal intensive care unit. In addition to known clinical risk factors, there are emerging data about genetic predisposition to PDA in both animal and human models. Clinical response and toxicity from drugs used to treat PDA are highly variable. Developmental and genetic aspects of pharmacokinetics and pharmacodynamics influence exposure and response to pharmacologic therapies. Given the variable efficacy and toxicity of known drug therapies, novel therapeutic targets for PDA treatment offer the promise of precision medicine. This review addresses the known genetic contributions to prolonged ductal patency, variability in response to drug therapy for PDA, and potential novel drug targets for future PDA treatment discovery.
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Affiliation(s)
- Tamorah R Lewis
- Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri, Kansas City School of Medicine, Kansas City, MO, USA
| | - Elaine L Shelton
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara L Van Driest
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Prince J Kannankeril
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeff Reese
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN, USA; Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA.
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19
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Abstract
Preterm infants are at increased risk for patent ductus arteriosus (PDA). Prolonged exposure to PDA may be deleterious and has been associated with neonatal morbidity and mortality. Although the molecular mechanisms underlying regulation of postnatal ductus arteriosus closure are not fully understood, clinical experience and research trials have informed recent changes in PDA management strategies and refocused treatment strategies on smaller subsets of infants who require intervention. This review examines current diagnostic and management approaches to PDA in preterm neonates.
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Affiliation(s)
- Maria Gillam-Krakauer
- Mildred T. Stahlman Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN
| | - Jeff Reese
- Mildred T. Stahlman Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN
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20
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Hu Y, Jin H, Jiang Y, Du J. Prediction of Therapeutic Response to Cyclooxygenase Inhibitors in Preterm Infants with Patent Ductus Arteriosus. Pediatr Cardiol 2018; 39:647-652. [PMID: 29468349 DOI: 10.1007/s00246-018-1831-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 02/14/2018] [Indexed: 01/16/2023]
Abstract
Patent ductus arteriosus (PDA) is a morbid condition commonly seen in premature infants. Cyclooxygenase (COX) inhibitors, such as indomethacin and ibuprofen, are often used for the treatment of PDA in preterm infants, and they work by reducing the production of prostaglandin. However, as observed in clinical practice, not all PDAs in preterm infants can be closed using COX inhibitors. Some studies have demonstrated that gestational age, birth weight, B-type natriuretic peptide (BNP), and ductal diameter can predict the therapeutic responsiveness to COX inhibitors. This paper reviews the factors that can predict successful closure of the PDA in preterm infants using indomethacin or ibuprofen and presents new opinions and recent findings on this topic, including the predictive roles of intrauterine growth restriction, timing of the treatment, and the importance of platelet count and arterial pH. We also discuss the prospects for future studies to improve the individualized therapy of PDA in premature neonates.
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Affiliation(s)
- Yang Hu
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China
| | - Yi Jiang
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China.
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China.
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21
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de Albuquerque Botura C, da Rocha BA, Balensiefer T, Ames FQ, Bersani-Amado CA, Nakamura Cuman RK. Oral pharmacological treatment for patent ductus arteriosus in premature neonates with hemodynamic repercussions. ASIAN PAC J TROP MED 2017; 10:1080-1083. [PMID: 29203106 DOI: 10.1016/j.apjtm.2017.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 08/29/2017] [Accepted: 09/16/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of oral indomethacin, ibuprofen, and paracetamol in oral dosage form on patent ductus arteriosus (PDA) in premature neonates with significant clinical and hemodynamic repercussions (CHRs) and to determine the effect of these respective treatments on renal function. METHODS A retrospective study of cases of PDA in premature neonates in the Neonatal Intensive Care Unit was conducted. The treatments consisted of indomethacin [0.2 mg/(kg·d), 3-day cycle], ibuprofen [10 mg/(kg·d) followed by 5 mg/(kg·d), 3-day cycle], and paracetamol (15 mg/kg every 6 h, 5-day cycle). The drugs were administered as an oral solution. The following variables were considered: gestational age, newborn weight at birth, Apgar score, diuresis, serum creatinine and urea levels, and serum electrolyte levels (sodium and potassium). RESULTS Treatment with indomethacin presented efficacy of 87.5% in closure of the ductus with a mean outcome period of 3.5 d. In premature neonates with CHRs and contraindications for indomethacin, the initial treatment with either ibuprofen or paracetamol failed to close the ductus. However, when this treatment was followed by indomethacin, closure occurred in 66.7% of the neonates, with an outcome period of 9.66 d. The initial treatment with one cycle of ibuprofen followed by one or two cycles of paracetamol failed to close the ductus. CONCLUSIONS Oral indomethacin was effective for closure of the PDA in premature neonates with severe CHRs. Oral paracetamol or ibuprofen for PDA closure in premature neonates with severe CHRs and contraindications for indomethacin was ineffective. However, results in clinical improvements of neonates allowed the subsequent use of indomethacin and successful closure of the ductus. A significant reduction of diuresis occurred in neonates who were treated with indomethacin, either as a first-line treatment or after the failure of ibuprofen or paracetamol.
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Affiliation(s)
| | - Bruno Ambrósio da Rocha
- Department of Pharmacology and Therapeutics, State University of Maringá, Maringá, Paraná, Brazil
| | | | - Franciele Queiroz Ames
- Department of Pharmacology and Therapeutics, State University of Maringá, Maringá, Paraná, Brazil
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Vilchez G, Dai J, Kumar K, Mundy D, Kontopoulos E, Sokol RJ. Racial/ethnic disparities in magnesium sulfate neuroprotection: a subgroup analysis of a multicenter randomized controlled trial. J Matern Fetal Neonatal Med 2017; 31:2304-2311. [PMID: 28612671 DOI: 10.1080/14767058.2017.1342795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Despite known racial disparities in obstetrics, as well as differences in magnesium pharmacodynamics according to race, the effect of race/ethnicity in magnesium sulfate (MgSO4) use during pregnancy has not been studied. Whether some mothers are at increased risk of side effects, or infants at decreased neuroprotective effects is unknown. We analyze the effect of race/ethnicity in maternal/infant outcomes after MgSO4 neuroprotection. STUDY DESIGN Subgroup analysis of a multicenter clinical trial (BEAM trial) where pregnant women at risk of preterm birth were randomized to either MgSO4 or placebo. For this study, nonanomalous singleton pregnancies were studied. The effect of race in maternal/neonatal outcomes after MgSO4 was analyzed with Breslow-Day and multifactorial ANOVA. Logistic regression was used to calculate odds ratios (OR) of complications according to race. RESULTS 922 MgSO4 and 972 placebo cases were included (45.0% African-American, 36.2% Caucasian, 17.8% Hispanics, and 1.0% Asians). Interaction analysis showed a significant effect of race/ethnicity (p = .043). Hispanics presented the highest frequency (88.3%, p < .001), as well as the highest odds of MgSO4 side effects [OR(95%CI) = 6.6 (1.3-33.8)]. CONCLUSION Hispanics present increased risk of magnesium toxicity compared to other racial/ethnic groups. Whether specific racial/ethnic groups require closer surveillance for early signs of magnesium toxicity needs to be further explored.
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Affiliation(s)
- Gustavo Vilchez
- a Department of Obstetrics and Gynecology , University of Missouri - Kansas City School of Medicine , Kansas City , MO , USA
| | - Jing Dai
- b Department of Obstetrics and Gynecology , Wayne State University School of Medicine , Detroit , MI , USA
| | - Komal Kumar
- a Department of Obstetrics and Gynecology , University of Missouri - Kansas City School of Medicine , Kansas City , MO , USA
| | - David Mundy
- a Department of Obstetrics and Gynecology , University of Missouri - Kansas City School of Medicine , Kansas City , MO , USA
| | - Eftichia Kontopoulos
- a Department of Obstetrics and Gynecology , University of Missouri - Kansas City School of Medicine , Kansas City , MO , USA
| | - Robert J Sokol
- b Department of Obstetrics and Gynecology , Wayne State University School of Medicine , Detroit , MI , USA
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Efficacy of pharmacologic closure of patent ductus arteriosus in small-for-gestational-age extremely preterm infants. Early Hum Dev 2017; 113:10-17. [PMID: 28697406 PMCID: PMC5654678 DOI: 10.1016/j.earlhumdev.2017.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/23/2017] [Accepted: 07/02/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Optimal management of the patent ductus arteriosus (PDA) in preterm infants remains controversial. Therefore, studies identifying infants who are most likely to benefit from PDA treatment are needed. AIM We sought to examine if significant intrauterine growth restriction, defined by birth weight z-score, reduces the efficacy of PDA closure with indomethacin or ibuprofen and thereby increases the need for surgical closure of PDA after pharmacologic treatment. STUDY DESIGN, SUBJECTS, AND OUTCOME MEASURES We studied infants 23-28weeks' gestation born 2006-2013 at NICHD Neonatal Research Network centers. We examined the responses to PDA treatment with indomethacin and/or ibuprofen and whether the PDA was subsequently closed surgically. Logistic regression generated adjusted odds ratios (ORs) for the associations between the z-score groups (<-2, -2 to -0.5, and >-0.5) and PDA surgery following pharmacologic treatment. RESULTS 5606 infants were diagnosed with PDA; 3587 (64.0%) received indomethacin or ibuprofen or both, and 909 (25.3%) underwent PDA surgery. Mothers of infants with PDA non-closure were less likely to have hypertension (19% vs. 28%). Infants with non-closure were more likely to be female (53% vs. 49%), have lower gestational age and birth weight and to develop sepsis (42% vs. 31%). Compared to infants with z-score>-0.5, PDA surgery was increased among infants with z-score -2 to -0.5 (OR=1.23; 95% CI 1.02-1.47) but not among infants with z-score<-2. CONCLUSION Infants with birth weight z-score -2 to -0.5 are more likely than normally grown infants to require PDA surgery following pharmacologic treatment.
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Terrin G, Conte F, Oncel MY, Scipione A, McNamara PJ, Simons S, Sinha R, Erdeve O, Tekgunduz KS, Dogan M, Kessel I, Hammerman C, Nadir E, Yurttutan S, Jasani B, Alan S, Manguso F, De Curtis M. Paracetamol for the treatment of patent ductus arteriosus in preterm neonates: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2016; 101:F127-36. [PMID: 26283668 DOI: 10.1136/archdischild-2014-307312] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 07/24/2015] [Indexed: 01/27/2023]
Abstract
OBJECTIVES We performed a systematic review and meta-analysis of all the available evidence to assess the efficacy and safety of paracetamol for the treatment of patent ductus arteriosus (PDA) in neonates, and to explore the effects of clinical variables on the risk of closure. DATA SOURCE MEDLINE, Scopus and ISI Web of Knowledge databases, using the following medical subject headings and terms: paracetamol, acetaminophen and patent ductus arteriosus. Electronic and manual screening of conference abstracts from international meetings of relevant organisations. Manual search of the reference lists of all eligible articles. STUDY SELECTION Studies comparing paracetamol versus ibuprofen, indomethacin, placebo or no intervention for the treatment of PDA. DATA EXTRACTION Data regarding efficacy and safety were collected and analysed. RESULTS Sixteen studies were included: 2 randomised controlled trials (RCTs) and 14 uncontrolled studies. Quality of selected studies is poor. A meta-analysis of RCTs does not demonstrate any difference in the risk of ductal closure (Mantel-Haenszel model, RR 1.07, 95% CI 0.87 to 1.33 and RR 1.03, 95% CI 0.92 to 1.16, after 3 and 6 days of treatment, respectively). Proportion meta-analysis of uncontrolled studies demonstrates a pooled ductal closure rate of 49% (95% CI 29% to 69%) and 76% (95% CI 61% to 88%) after 3 and 6 days of treatment with paracetamol, respectively. Safety profiles of paracetamol and ibuprofen are similar. CONCLUSIONS Efficacy and safety of paracetamol appear to be comparable with those of ibuprofen. These results should be interpreted with caution, taking into account the non-optimal quality of the studies analysed and the limited number of neonates treated with paracetamol so far.
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Affiliation(s)
- Gianluca Terrin
- Department of Gynecology-Obstetrics and Perinatal Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesca Conte
- Department of Pediatrics and Pediatric Neuropsychiatry, Sapienza University of Rome, Rome, Italy
| | - Mehmet Yekta Oncel
- Division of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Antonella Scipione
- Department of Pediatrics and Pediatric Neuropsychiatry, Sapienza University of Rome, Rome, Italy
| | - Patrick J McNamara
- Department of Neonatology, The Hospital for Sick Children, Toronto, Canada
| | - Sinno Simons
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rahul Sinha
- Department of Pediatrics and Neonatology, 167 Military Hospital, Pathankot, Punjab, India
| | - Omer Erdeve
- Division of Neonatology, Department of Pediatrics, Ankara University School of Medicine Children's Hospital, Ankara, Turkey
| | - Kadir S Tekgunduz
- Department of Neonatology, Ataturk University Medical Faculty, Erzurum, Turkey
| | - Mustafa Dogan
- Division of Cardiology, Department of Pediatrics, Pamukkale University, Denizli, Turkey
| | - Irena Kessel
- Department of Neonatology, Carmel Medical Center, Haifa, Israel
| | - Cathy Hammerman
- Department of Neonatology, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - E Nadir
- Department of Neonatology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Sadik Yurttutan
- Division of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Bonny Jasani
- Department of Neonatology, KEM Hospital, Mumbai, India
| | - Serdar Alan
- Division of Neonatology, Hitit University, Corum, Turkey
| | | | - Mario De Curtis
- Department of Pediatrics and Pediatric Neuropsychiatry, Sapienza University of Rome, Rome, Italy
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Yamaguchi H, Wada K, Nagasawa M, Kikusui T, Sakai H, Mizobuchi M, Yoshimoto S, Nakao H. Very Low Birth Weight Monochorionic Diamniotic Twins as a Risk Factor for Symptomatic Patent Ductus Arteriosus. Neonatology 2016; 109:228-34. [PMID: 26859415 DOI: 10.1159/000442968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 12/02/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Some prior studies have shown that symptomatic patent ductus arteriosus (sPDA) is highly familial. Although it is estimated that both genetic and environmental factors may contribute to sPDA, evidence is still lacking. OBJECTIVE The aim of this study was to determine the risk factors for sPDA, focusing on the genetic and in utero environment by analyzing very low birth weight (VLBW) singletons and twins. METHODS This retrospective case-control study reviewed the medical records of 445 VLBW infants (25 weeks ≤ gestational age <32 weeks, 600 g ≤ birth weight <1,500 g) and compared the incidence of sPDA among monochorionic diamniotic (MD) twins (n = 65), dichorionic diamniotic (DD) twins (n = 66), and singletons (n = 314). RESULTS Stepwise multiple regression analysis showed that twin siblings (p = 0.001), gestational week (p < 0.001), antenatal steroid use (p = 0.021), and premature rupture of membranes (p = 0.002) were independent predictors of sPDA. Incidence of sPDA in MD twin siblings was significantly higher than that in singletons (p < 0.01), whereas no significant difference was found between singletons and DD twins or between MD and DD twins. CONCLUSIONS The current results show that being a VLBW MD twin is an independent risk factor for sPDA, and that both genetic and in utero environmental factors may contribute to its development.
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Affiliation(s)
- Hiroshi Yamaguchi
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
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26
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Effects of Advancing Gestation and Non-Caucasian Race on Ductus Arteriosus Gene Expression. J Pediatr 2015; 167:1033-41.e2. [PMID: 26265282 PMCID: PMC4661123 DOI: 10.1016/j.jpeds.2015.07.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 06/26/2015] [Accepted: 07/08/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To identify genes affected by advancing gestation and racial/ethnic origin in human ductus arteriosus (DA). STUDY DESIGN We collected 3 sets of DA tissue (n = 93, n = 89, n = 91; total = 273 fetuses) from second trimester pregnancies. We examined four genes, with DNA polymorphisms that distribute along racial lines, to identify "Caucasian" and "non-Caucasian" DA. We used real time polymerase chain reaction to measure RNA expression of 48 candidate genes involved in functional closure of the DA, and used multivariable regression analyses to examine the relationships between advancing gestation, "non-Caucasian" race, and gene expression. RESULTS Mature gestation and non-Caucasian race are significant predictors for identifying infants who will close their patent DA when treated with indomethacin. Advancing gestation consistently altered gene expression in pathways involved with oxygen-induced constriction (eg, calcium-channels, potassium-channels, and endothelin signaling), contractile protein maturation, tissue remodeling, and prostaglandin and nitric oxide signaling in all 3 tissue sets. None of the pathways involved with oxygen-induced constriction appeared to be altered in "non-Caucasian" DA. Two genes, SLCO2A1 and NOS3, (involved with prostaglandin reuptake/metabolism and nitric oxide production, respectively) were consistently decreased in "non-Caucasian" DA. CONCLUSIONS Prostaglandins and nitric oxide are the most important vasodilators opposing DA closure. Indomethacin inhibits prostaglandin production, but not nitric oxide production. Because decreased SLCO2A1 and NOS3 expression can lead to increased prostaglandin and decreased nitric oxide concentrations, we speculate that prostaglandin-mediated vasodilation may play a more dominant role in maintaining the "non-Caucasian" patent DA, making it more likely to close when inhibited by indomethacin.
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27
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Ahamed MF, Verma P, Lee S, Vega M, Wang D, Kim M, Fuloria M. Predictors of successful closure of patent ductus arteriosus with indomethacin. J Perinatol 2015; 35:729-34. [PMID: 25856764 DOI: 10.1038/jp.2015.33] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 02/11/2015] [Accepted: 03/02/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine whether platelet counts can predict the likelihood of successful closure of patent ductus arteriosus (PDA) with indomethacin. STUDY DESIGN This was a retrospective cohort study of infants <32 weeks' gestational age (GA) and birth weight <1500 g with PDA. Clinical characteristics between infants who achieved ductal closure with indomethacin and those who failed were compared. Multivariable logistic regression was used to identify predictors of successful ductal closure. RESULTS In infants with hemodynamically significant PDA, older GA (odds ratio=1.54; 95% confidence interval: 1.12 to 2.13), male gender (odds ratio=3.02; 95% confidence interval: 1.08 to 8.49) and higher platelet count (odds ratio=1.5; 95% confidence interval: 1.04 to 2.17) prior to indomethacin treatment were associated with successful ductal closure with indomethacin. CONCLUSION Older GA, male gender and higher platelet count at time of treatment of hemodynamically significant PDA are predictors of successful ductal closure with indomethacin.
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Affiliation(s)
- M F Ahamed
- Division of Neonatal-Perinatal Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - P Verma
- Division of Neonatology, Alpert Medical School of Brown University, Providence, RI, USA
| | - S Lee
- Division of Pediatric Cardiology, Mount Sinai Hospital, Icahn School of Medicine, New York, NY, USA
| | - M Vega
- Division of Neonatal-Perinatal Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - D Wang
- Department of Epidemiology & Population Health, Division of Biostatistics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - M Kim
- Department of Epidemiology & Population Health, Division of Biostatistics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - M Fuloria
- Division of Neonatal-Perinatal Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
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28
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Vucovich MM, Cotton RB, Shelton EL, Goettel JA, Ehinger NJ, Poole SD, Brown N, Wynn JL, Paria BC, Slaughter JC, Clark RH, Rojas MA, Reese J. Aminoglycoside-mediated relaxation of the ductus arteriosus in sepsis-associated PDA. Am J Physiol Heart Circ Physiol 2014; 307:H732-40. [PMID: 24993047 PMCID: PMC4187398 DOI: 10.1152/ajpheart.00838.2013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 06/27/2014] [Indexed: 11/22/2022]
Abstract
Sepsis is strongly associated with patency of the ductus arteriosus (PDA) in critically ill newborns. Inflammation and the aminoglycoside antibiotics used to treat neonatal sepsis cause smooth muscle relaxation, but their contribution to PDA is unknown. We examined whether: 1) lipopolysaccharide (LPS) or inflammatory cytokines cause relaxation of the ex vivo mouse DA; 2) the aminoglycosides gentamicin, tobramycin, or amikacin causes DA relaxation; and 3) newborn infants treated with aminoglycosides have an increased risk of symptomatic PDA (sPDA). Changes in fetal mouse DA tone were measured by pressure myography in response to LPS, TNF-α, IFN-γ, macrophage-inflammatory protein 2, IL-15, IL-13, CXC chemokine ligand 12, or three aminoglycosides. A clinical database of inborn patients of all gestations was analyzed for association between sPDA and aminoglycoside treatment. Contrary to expectation, neither LPS nor any of the inflammatory mediators caused DA relaxation. However, each of the aminoglycosides caused concentration-dependent vasodilation in term and preterm mouse DAs. Pretreatment with indomethacin and N-(G)-nitro-L-arginine methyl ester did not prevent gentamicin-induced DA relaxation. Gentamicin-exposed DAs developed less oxygen-induced constriction than unexposed DAs. Among 488,349 infants who met the study criteria, 40,472 (8.3%) had sPDA. Confounder-adjusted odds of sPDA were higher in gentamicin-exposed infants, <25 wk and >32 wk. Together, these findings suggest that factors other than inflammation contribute to PDA. Aminoglycoside-induced vasorelaxation and inhibition of oxygen-induced DA constriction support the paradox that antibiotic treatment of sepsis may contribute to DA relaxation. This association was also found in newborn infants, suggesting that antibiotic selection may be an important consideration in efforts to reduce sepsis-associated PDA.
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Affiliation(s)
- Megan M Vucovich
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Robert B Cotton
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Elaine L Shelton
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Jeremy A Goettel
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Noah J Ehinger
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Stanley D Poole
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Naoko Brown
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - James L Wynn
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Bibhash C Paria
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Mario A Rojas
- Department of Pediatrics, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Jeff Reese
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee; Department of Cell and Developmental Biology, Vanderbilt University School of Medicine, Nashville, Tennessee;
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Predictors of bronchopulmonary dysplasia or death in premature infants with a patent ductus arteriosus. Pediatr Res 2014; 75:570-5. [PMID: 24378897 PMCID: PMC3961500 DOI: 10.1038/pr.2013.253] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 09/27/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND Preterm infants with a patent ductus arteriosus (PDA) are at risk for death or development of bronchopulmonary dysplasia (BPD). However, PDA treatment remains controversial. We investigated if PDA treatment and other clinical or echocardiographic (ECHO) factors were associated with the development of death or BPD. METHODS We retrospectively studied clinical and ECHO characteristics of preterm infants with birth weight <1,500 g and ECHO diagnosis of a PDA. Logistic regression and classification and regression tree analyses were performed to assess variables associated with the combined outcome of death or BPD. RESULTS Of 187 preterm infants with a PDA, 75% were treated with indomethacin or surgical ligation and 25% were managed conservatively. Death or BPD occurred in 80 (43%) infants. The results of logistic regression analyses showed that lower gestational age (odds ratio (OR): 0.5), earlier year of birth during the study period (OR: 0.9), and larger ductal diameter (OR: 4.3) were associated with the decision to treat the PDA, whereas gestational age was the only variable associated with death or BPD (OR: 0.6; 95% confidence interval: 0.5-0.8). CONCLUSION Only lower gestational age and not PDA treatment or ECHO score was associated with the adverse outcome of death or BPD. Further investigation of PDA management strategies and effects on adverse outcomes of prematurity is needed.
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Terrin G, Conte F, Scipione A, Bacchio E, Conti MG, Ferro R, Ventriglia F, De Curtis M. Efficacy of paracetamol for the treatment of patent ductus arteriosus in preterm neonates. Ital J Pediatr 2014; 40:21. [PMID: 24555510 PMCID: PMC3940001 DOI: 10.1186/1824-7288-40-21] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 02/16/2014] [Indexed: 02/06/2023] Open
Abstract
Inhibitors of the cyclo-oxygenase component of prostaglandin-H2 synthetase, namely indomethacin and ibuprofen, are commonly used in the treatment of hemodynamically significant patent ductus arteriosus. These drugs are associated with serious adverse events, including gastrointestinal perforation, renal failure and bleeding. The role of paracetamol, an inhibitor of the peroxidase component of prostaglandin-H2 synthetase, has been proposed for the treatment of patent ductus arteriosus. We report a series of 8 neonates (birth weight: 724 ± 173 g; gestational age: 26 ± 2 weeks) treated with paracetamol for a hemodynamically significant patent ductus arteriosus, because of contraindications to ibuprofen or indomethacin. Successful closure was achieved in 6 out of 8 babies (75%). Median ductal diameter was significantly reduced after treatment (from 1.2 mm, range 1.0-2.5 mm to 0.6 mm, range 0.0-2.5 mm, p = 0.038). No adverse or side effects were observed during treatment. On the basis of these results, paracetamol could be considered a promising and safe therapy for the treatment of patent ductus arteriosus in neonates.
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Affiliation(s)
- Gianluca Terrin
- Department of Gynecology-Obstetrics and Perinatal Medicine, University "La Sapienza", Viale del Policlinico 155, 00161 Rome, Italy.
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31
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Chen YY, Wang HP, Chang JT, Chiou YH, Huang YF, Hsieh KS. Perinatal factors in patent ductus arteriosus in very low-birthweight infants. Pediatr Int 2014; 56:72-6. [PMID: 23937654 DOI: 10.1111/ped.12199] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 06/30/2013] [Accepted: 08/06/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The relationship between hemoglobin and patent ductus arteriosus (PDA) has not been discussed before. The aim of this study was to assess the influence of hemoglobin and perinatal factors on PDA in very low-birthweight (VLBW) infants. METHODS Using data from the Premature Baby Foundation of Taiwan (PBFA), the characteristics, perinatal factors, and hemoglobin of VLBW infants with and without PDA and treatment were compared. RESULTS Between January 2008 and December 2010, 89 VLBW infants were admitted to hospital. The overall survival rate was 87.6%. Twelve infants were excluded. Compared to those without PDA, the 34 infants with PDA received oral indomethacin or surgery, had smaller mean gestational age (GA; 27.93 ± 1.818 weeks, P = 0.000003), lower mean birthweight (BW; 1031 ± 259 g, P = 0.0001), significantly lower Apgar score at 5 min, more severe respiratory distress syndrome (RDS; grade 3 or 4), greater use of surfactants, and lower mean hemoglobin (P = 0.018) after birth than those without PDA. Compared to those with indomethacin, the seven infants with surgery had lower mean GA (26.43 ± 1.718 weeks, P = 0.011), significantly lower Apgar scores at 1 min, but higher platelet count (P = 0.002) after birth, and more red blood cell transfusions (P = 0.039). CONCLUSIONS Smaller GA, lower BW, lower Apgar score at 5 min, more severe RDS, greater use of surfactants, and lower hemoglobin after birth place VLBW infants at greater risk of PDA. Proper prenatal care, and prevention of premature labor and delivery may be the most important preventative factors. The appropriate hemoglobin level for PDA closure requires further investigation.
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Affiliation(s)
- Ying-Yao Chen
- Division of Neonatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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32
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Cotton RB, Shah LP, Poole SD, Ehinger NJ, Brown N, Shelton EL, Slaughter JC, Baldwin HS, Paria BC, Reese J. Cimetidine-associated patent ductus arteriosus is mediated via a cytochrome P450 mechanism independent of H2 receptor antagonism. J Mol Cell Cardiol 2013; 59:86-94. [PMID: 23454087 DOI: 10.1016/j.yjmcc.2013.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 02/02/2013] [Accepted: 02/18/2013] [Indexed: 01/13/2023]
Abstract
Persistent patency of the ductus arteriosus (PDA) is a common problem in preterm infants. The antacid cimetidine is a potent antagonist of the H2 histamine receptor but it also inhibits certain cytochrome P450 enzymes (CYPs), which may affect DA patency. We examined whether cimetidine contributes to PDA and is mediated by CYP inhibition rather than H2 blockade. Analysis of a clinical trial to prevent lung injury in premature infants revealed a significant association between cimetidine treatment and PDA. Cimetidine and ranitidine, both CYP inhibitors as well as H2 blockers, caused relaxation of the term and preterm mouse DA. CYP enzymes that are inhibited by cimetidine were expressed in DA subendothelial smooth muscle. The selective CYP3A inhibitor ketoconazole induced greater DA relaxation than cimetidine, whereas famotidine and other H2 antagonists with less CYP inhibitory effects caused less dilation. Histamine receptors were developmentally regulated and localized in DA smooth muscle. However, cimetidine caused DA relaxation in histamine-deficient mice, consistent with CYP inhibition, not H2 antagonism, as the mechanism for PDA. Oxygen-induced DA constriction was inhibited by both cimetidine and famotidine. These studies show that antacids and other compounds with CYP inhibitory properties pose a significant and previously unrecognized risk for PDA in critically ill newborn infants.
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Affiliation(s)
- Robert B Cotton
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN 37232, USA
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33
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A high ductal flow velocity is associated with successful pharmacological closure of patent ductus arteriosus in infants 22-27 weeks gestational age. Crit Care Res Pract 2012; 2012:715265. [PMID: 23316351 PMCID: PMC3535826 DOI: 10.1155/2012/715265] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 11/10/2012] [Accepted: 11/10/2012] [Indexed: 11/18/2022] Open
Abstract
Objective. To identify factors affecting closure of patent ductus arteriosus (PDA) in newborn infants born at 22–27 weeks gestational age (GA) during pharmacological treatment with cyclooxygenase inhibitors. Method. Infants born at 22–27 weeks of GA between January 2006 and December 2009 who had been treated pharmacologically for PDA were identified retrospectively. Medical records were assessed for clinical, ventilatory, and outcome parameters. Echocardiographic examinations during treatment were reviewed. Results. Fifty-six infants were included in the study. Overall success rate of ductal closure with pharmacological treatment was 52%. Infants whose PDA was successfully closed had a higher GA (25 + 4 weeks versus 24 + 3 weeks; P = 0.047), and a higher pretreatment left to right maximal ductal flow velocity (1.6 m/s versus 1.1 m/s; P = 0.023). Correcting for GA, preeclampsia, antenatal steroids, and age at start of treatment, a higher maximal ductal flow velocity was still associated with successful ductal closure (OR 3.04; P = 0.049). Conclusion. Maximal ductal flow velocity was independently associated with success of PDA treatment.
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Mezu-Ndubuisi OJ, Agarwal G, Raghavan A, Pham JT, Ohler KH, Maheshwari A. Patent ductus arteriosus in premature neonates. Drugs 2012; 72:907-16. [PMID: 22564132 DOI: 10.2165/11632870-000000000-00000] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Persistent patency of the ductus arteriosus is a major cause of morbidity and mortality in premature infants. In infants born prior to 28 weeks of gestation, a haemodynamically significant patent ductus arteriosus (PDA) can cause cardiovascular instability, exacerbate respiratory distress syndrome, prolong the need for assisted ventilation and increase the risk of bronchopulmonary dysplasia, intraventricular haemorrhage, renal dysfunction, cerebral palsy and mortality. We review the pathophysiology, clinical features and assessment of haemodynamic significance, and provide a rigorous appraisal of the quality of evidence to support current medical and surgical management of PDA of prematurity. Cyclo-oxygenase inhibitors such as indomethacin and ibuprofen remain the mainstay of medical therapy for PDA, and can be used both for prophylaxis as well as for rescue therapy to achieve PDA closure. Surgical ligation is also effective and is used in infants who do not respond to medical management. Although both medical and surgical treatment have proven efficacy in closing the ductus, both modalities are associated with significant adverse effects. Because the ductus does undergo spontaneous closure in some premature infants, improved and early identification of infants most likely to develop a symptomatic PDA could help in directing treatment to the at-risk infants and allow others to receive expectant management.
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Affiliation(s)
- Olachi J Mezu-Ndubuisi
- Division of Neonatology, Department of Pediatrics, University of Illinois at Chicago, Chicago, IL 60612, USA
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Abstract
Closure of the ductus arteriosus at birth is a complex phenomenon being conditioned by antenatal events and progressing in preprogrammed steps. Functional at first, narrowing of the vessel is determined by 2 overlapping processes--removal of the prostaglandin E(2)-based relaxation sustaining prenatal patency and activation of a constrictor mechanism by the natural rise in blood oxygen tension. Two schemes have been proposed for oxygen action--one involving a cytochrome P450 hemoprotein (sensor)/endothelin-1 (effector) complex and the other a set of voltage-gated K(+) channels. These proposals, however, are not mutually exclusive. Structural closure follows the constriction through a remodeling process initiated antenatally with the development of intimal cushions and completed postnatally by a host of humoral and mechanical stimuli. Research in this area has already provided clinical applications. Nevertheless, management of premature infants with persistent ductus remains troublesome and calls for an alternative approach to the prostaglandin E(2) inhibitors now in use. Studies in progress on the oxygen-sensing system may lead to a definitive solution for this problem.
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Affiliation(s)
- Flavio Coceani
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.
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Clyman RI, Couto J, Murphy GM. Patent ductus arteriosus: are current neonatal treatment options better or worse than no treatment at all? Semin Perinatol 2012; 36:123-9. [PMID: 22414883 PMCID: PMC3305915 DOI: 10.1053/j.semperi.2011.09.022] [Citation(s) in RCA: 178] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Although a moderate-sized patent ductus arteriosus (PDA) needs to be closed by the time a child is 1-2 years old, there is great uncertainty about whether it needs to be closed during the neonatal period. Although 95% of neonatologists believe that a moderate-sized PDA should be closed if it persists in infants (born before 28 weeks) who still require mechanical ventilation, the number of neonatologists who treat a PDA when it occurs in infants who do not require mechanical ventilation varies widely. Both the high likelihood of spontaneous ductus closure and the absence of randomized controlled trials, specifically addressing the risks and benefits of neonatal ductus closure, add to the current uncertainty. New information suggests that early pharmacologic treatment has several important short-term benefits for the preterm newborn. By contrast, ductus ligation, while eliminating the detrimental effects of a PDA on lung development, may create its own set of morbidities that counteract many of the benefits derived from ductus closure.
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MESH Headings
- Cardiovascular Agents/therapeutic use
- Ductus Arteriosus, Patent/drug therapy
- Ductus Arteriosus, Patent/physiopathology
- Ductus Arteriosus, Patent/surgery
- Ductus Arteriosus, Patent/therapy
- Female
- Humans
- Indomethacin/therapeutic use
- Infant, Newborn
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/physiopathology
- Infant, Premature, Diseases/surgery
- Ligation
- Male
- Pregnancy
- Respiration, Artificial
- Unnecessary Procedures
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Affiliation(s)
- Ronald I Clyman
- Department of Pediatrics, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143, USA.
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37
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Johnston PG, Gillam-Krakauer M, Fuller MP, Reese J. Evidence-based use of indomethacin and ibuprofen in the neonatal intensive care unit. Clin Perinatol 2012; 39:111-36. [PMID: 22341541 PMCID: PMC3598606 DOI: 10.1016/j.clp.2011.12.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Indomethacin and ibuprofen are potent inhibitors of prostaglandin synthesis. Neonates have been exposed to these compounds for more than 3 decades. Indomethacin is commonly used to prevent intraventricular hemorrhage (IVH), and both drugs are prescribed for the treatment or prevention of patent ductus arteriosus (PDA). This review examines the basis for indomethacin and ibuprofen use in the neonatal intensive care population. Despite the call for restrained use of each drug, the most immature infants are likely to need pharmacologic approaches to reduce high-grade IVH, avoid the need for PDA ligation, and preserve the opportunity for an optimal outcome.
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Affiliation(s)
- Palmer G. Johnston
- Neonatal-Perinatal Medicine, Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children’s Way, Doctor’s Office Tower 11111, Nashville, TN 37232-9544, USA
| | - Maria Gillam-Krakauer
- Neonatal-Perinatal Medicine, Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children’s Way, Doctor’s Office Tower 11111, Nashville, TN 37232-9544, USA
| | - M. Paige Fuller
- Department of Pharmacy, Monroe Carell Jr. Children’s Hospital at Vanderbilt, 2200 Children’s Way, Room 4508, Nashville, TN 37232, USA
| | - Jeff Reese
- Neonatal-Perinatal Medicine, Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children’s Way, Doctor’s Office Tower 11111, Nashville, TN 37232-9544, USA,Department of Cell and Developmental Biology, Vanderbilt University Medical Center, U-3218 MRB III Building, Nashville, TN 37232-8240, USA,Corresponding author. Department of Cell and Developmental Biology, Vanderbilt University Medical Center, U-3218 MRB III Building, Nashville, TN 37232-8240.,
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38
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Patent ductus arteriosus in infants <29 weeks gestation — outcomes and factors affecting closure. Indian Pediatr 2012; 49:615-20. [DOI: 10.1007/s13312-012-0132-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Accepted: 10/19/2011] [Indexed: 11/27/2022]
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Shah NA, Hills NK, Waleh N, McCurnin D, Seidner S, Chemtob S, Clyman R. Relationship between circulating platelet counts and ductus arteriosus patency after indomethacin treatment. J Pediatr 2011; 158:919-923.e1-2. [PMID: 21195414 PMCID: PMC3095765 DOI: 10.1016/j.jpeds.2010.11.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Revised: 10/18/2010] [Accepted: 11/05/2010] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether low platelet counts are related to the incidence of patent ductus arteriosus (PDA) after indomethacin treatment in preterm human infants. STUDY DESIGN Multivariable logistic regression modeling was used for a cohort of 497 infants, who received indomethacin (within 15 hours of birth). RESULTS Platelet counts were not related to the incidence of permanent closure after indomethacin constriction. There was a relationship between platelet counts and the initial degree of constriction; however, this relationship appeared to be primarily influenced by the high end of the platelet distribution curve. PDA incidence was similar in infants with platelet counts < 50 × 10⁹/L and those with platelet counts above this range. Only when platelet counts were consistently >230 ×10⁹/L was there a decrease in PDA incidence. CONCLUSION In contrast to the evidence in mice, low circulating platelet counts do not affect permanent ductus closure (or ductus reopening) in human preterm infants.
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Affiliation(s)
- Nidhi A. Shah
- Department of Pediatrics, University of California San Francisco, CA 94143
| | - Nancy K. Hills
- Department of Neurology, University of California San Francisco, CA 94143
| | - Nahid Waleh
- Pharmaceutical Discovery Division, SRI International, Menlo Park, CA 94025
| | - Donald McCurnin
- Department of Pediatrics, University of Texas, Health Science Center, San Antonio, TX, 78229, Southwest Foundation for Biomedical Research, San Antonio TX, 78227
| | - Steven Seidner
- Department of Pediatrics, University of Texas, Health Science Center, San Antonio, TX, 78229, Southwest Foundation for Biomedical Research, San Antonio TX, 78227
| | - Sylvain Chemtob
- Departments of Pediatrics, Ophthalmology and Pharmacology Research Center, Hôpital Ste. Justine, Montreal, Quebec, H3T-1C5, Canada
| | - Ronald Clyman
- Department of Pediatrics, University of California San Francisco, CA 94143, Cardiovascular Research Institute, University of California San Francisco, CA 94143
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Kim ES, Kim EK, Choi CW, Kim HS, Kim BI, Choi JH, Park JS, Moon KC. Intrauterine inflammation as a risk factor for persistent ductus arteriosus patency after cyclooxygenase inhibition in extremely low birth weight infants. J Pediatr 2010; 157:745-50.e1. [PMID: 20598319 DOI: 10.1016/j.jpeds.2010.05.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 04/19/2010] [Accepted: 05/07/2010] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To test the hypothesis that intrauterine inflammation increases prostaglandin production and may be a risk factor for persistent ductus arteriosus after therapy with indomethacin, a nonselective cyclooxygenase inhibitor. STUDY DESIGN Indomethacin therapy was started after confirming ductus arteriosus within 24 hours after birth in extremely low birth weight infants. After one cycle of therapy, infants with closed ductus were classified as responders, and those with patent ductus were classified as nonresponders. Multiple logistic regression analysis was used to determine important perinatal factors associated with persistent ductus arteriosus. Immunohistochemistry with cyclooxygenase antibodies and radioimmunoassay by 6-keto prostaglandin F(1α) kit were used to determine the relationship between intrauterine inflammation and ductal patency. RESULTS Forty-one infants were responders, and 37 infants were nonresponders. Responders were frequently small for gestational age; nonresponders frequently had lower gestational age, respiratory distress syndrome, and intrauterine inflammation. By multiple logistic regression analysis, respiratory distress syndrome and intrauterine inflammation were more frequent in nonresponders. Cyclooxygenase-1 expression in the umbilical arteries and plasma 6-keto prostaglandin F(1α) levels were higher in nonresponders. CONCLUSIONS Respiratory distress syndrome and intrauterine inflammation were independent risk factors for persistent ductus arteriosus after indomethacin therapy in extremely low-birth weight infants. Intrauterine inflammation may have a negative influence on ductus arteriosus closure via increased cyclooxygenase-1 activity.
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Affiliation(s)
- Eun Sun Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
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Waleh N, Hodnick R, Jhaveri N, McConaghy S, Dagle J, Seidner S, McCurnin D, Murray JC, Ohls R, Clyman RI. Patterns of gene expression in the ductus arteriosus are related to environmental and genetic risk factors for persistent ductus patency. Pediatr Res 2010; 68:292-7. [PMID: 20581741 PMCID: PMC2940964 DOI: 10.1203/pdr.0b013e3181ed8609] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Three independent risk factors (immature gestation, absence of antenatal glucocorticoid exposure, and presence of the rs2817399(A) allele of the gene TFAP2B) are associated with patent ductus arteriosus (PDAs) that fail to close during prostaglandin inhibition. We hypothesized that these three factors may affect a common set of genes that increase the risk of persistent PDA after birth. We studied baboon ductus from term, preterm, and glucocorticoid-treated preterm fetuses and found that both immature gestation and absence of antenatal glucocorticoid exposure decreased RNA expression of calcium- and potassium-channel genes involved in oxygen-induced constriction, and phosphodiesterase genes (that modulate cAMP/cGMP signaling). Ductus obtained from second trimester human pregnancies were genotyped for TFAP2B polymorphisms. When present, the rs2817399(A) allele also was associated with decreased expression of calcium- and potassium-channel genes. In contrast, alleles of two other TFAP2B polymorphisms, rs2817419(G) and rs2635727(T), which are not related to the incidence of PDA after birth, had no effect on RNA expression. In conclusion, three calcium- and potassium-channel genes (CACNA1G/ alpha1G, CACNB 2/CaL-beta2, and KCNA2/ Kv1.2) were similarly affected by each of the PDA risk factors. We speculate that these channels may play a significant role in closing the preterm ductus during prostaglandin inhibition and may be potential targets for future pharmacologic manipulations.
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Affiliation(s)
- Nahid Waleh
- Pharmaceutical Discovery Division, SRI International, Menlo Park, California 94025, USA
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Rosito G, Sum K, Chorne N. ORIGINAL ARTICLE: Comparison of Two Neonatal Indomethacin Protocols: Efficacy and Outcome for Patent Ductus Arteriosus Closure. J Clin Pharm Ther 2010; 35:589-92. [DOI: 10.1111/j.1365-2710.2009.01142.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Reese J, Veldman A, Shah L, Vucovich M, Cotton RB. Inadvertent relaxation of the ductus arteriosus by pharmacologic agents that are commonly used in the neonatal period. Semin Perinatol 2010; 34:222-30. [PMID: 20494739 PMCID: PMC2920501 DOI: 10.1053/j.semperi.2010.02.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Premature birth and disruption of the normal maturation process leave the immature ductus arteriosus unable to respond to postnatal cues for closure. Strategies that advocate conservative management of the patent ductus arteriosus (PDA) in premature infants are dependent on identification of the symptomatic PDA and understanding the risk factors that predispose to PDA. Exposure of premature infants to unintended vasodilatory stimuli may be one of the risk factors for PDA that is under recognized. In this article, we summarize the clinical factors that are associated with PDA and review commonly used neonatal drugs for their vasodilatory properties. Data demonstrating relaxation of the ductus arteriosus by gentamicin and other aminoglycoside antibiotics, by cimetidine and other H2 receptor antagonists, and by heparin are provided as examples of neonatal therapies that have unanticipated effects that may promote PDA.
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Affiliation(s)
- Jeff Reese
- Department of Pediatrics, Monroe Carrell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Alex Veldman
- Monash Newborn and Ritchie Centre for Baby Health Research, Monash Medical Centre and Monash Institute of Medical Research, 246 Clayton Road, Clayton 3168, Melbourne, VIC, Australia
| | - Lisa Shah
- Southern Illinois University School of Medicine, Springfield, IL
| | - Megan Vucovich
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Robert B. Cotton
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
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Soraisham AS, Dalgleish S, Singhal N. Antenatal Indomethacin Tocolysis Is Associated With an Increased Need for Surgical Ligation of Patent Ductus Arteriosus in Preterm Infants. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2010; 32:435-442. [DOI: 10.1016/s1701-2163(16)34496-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Current world literature. Curr Opin Pediatr 2009; 21:272-80. [PMID: 19307901 DOI: 10.1097/mop.0b013e32832ad5c0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Reese J, O'Mara PW, Poole SD, Brown N, Tolentino C, Eckman DM, Aschner JL. Regulation of the fetal mouse ductus arteriosus is dependent on interaction of nitric oxide and COX enzymes in the ductal wall. Prostaglandins Other Lipid Mediat 2008; 88:89-96. [PMID: 19049898 DOI: 10.1016/j.prostaglandins.2008.11.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 11/04/2008] [Indexed: 12/16/2022]
Abstract
Nitric oxide (NO) and cyclooxygenase (COX)-derived prostaglandins are critical regulators of the fetal ductus arteriosus. To examine the interaction of these pathways within the ductus wall, the ductus arteriosus of term and preterm fetal mice was evaluated by pressurized myography. The isolated preterm ductus was more sensitive to NOS inhibition than at term. Sequential NOS and COX inhibition caused 36% constriction of the preterm ductus regardless of drug order. In contrast, constriction of the term ductus was dependent on the sequence of inhibition; NOS inhibition prior to COX inhibition produced greater constriction than when inhibitors were given in reverse order (36+/-6% versus 23+/-5%). Selective COX-1 or COX-2 inhibition prior to N(G)-nitro-l-arginine methyl ester (l-NAME) induced the expected degree of constriction. However, NOS inhibition followed by selective COX-2 inhibition caused unexpected ductal dilation. These findings are consistent with NO-induced activation of COX in the ductus arteriosus wall and the production of a COX-2-derived constrictor prostanoid that contributes to the balance of vasoactive forces that maintain fetal ductus arteriosus tone.
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Affiliation(s)
- Jeff Reese
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232-0656, USA.
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Lavoie PM, Pham C, Jang KL. Heritability of bronchopulmonary dysplasia, defined according to the consensus statement of the national institutes of health. Pediatrics 2008; 122:479-85. [PMID: 18762515 PMCID: PMC4631604 DOI: 10.1542/peds.2007-2313] [Citation(s) in RCA: 168] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The goal was to determine the magnitude of genetic effects on susceptibility and risk factors for bronchopulmonary dysplasia by using the clinically validated National Institutes of Health consensus definition as a demonstrated proxy for long-term respiratory and neurodevelopmental outcomes in extremely low birth weight infants. METHODS We analyzed clinical data from twin pairs born at </=30 completed weeks of gestation in British Columbia, Canada, between 1993 and 2006. Differences in correlations between monozygotic and dizygotic twin pairs and model-fitting approaches were used to quantify the relative contributions of genetic, shared environmental, and nonshared environmental effects. RESULTS Among 318 twins of known zygosity, monozygotic twin pair similarities were greater than those observed for dizygotic pairs, which suggests significant heritability for bronchopulmonary dysplasia. Model-fitting analyses confirmed that genetic effects accounted for 82% and 79% of the observed variance in bronchopulmonary dysplasia susceptibility, defined on the basis of the need for supplemental oxygen at 36 weeks or the National Institutes of Health consensus definition, respectively. Variations in rates of hemodynamically significant patent ductus arteriosus were largely accounted for by genetic effects, whereas the observed variability in susceptibility to blood-borne bacterial infections was largely attributable to environmental factors, both common and unique to each infant. CONCLUSIONS Susceptibility to bronchopulmonary dysplasia and persistence of patent ductus arteriosus are both significantly heritable. Our study strengthens the case for investigating genetic risk stratification markers useful for predicting the most significant long-term respiratory and neurodevelopmental consequences of bronchopulmonary dysplasia in premature neonates.
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Affiliation(s)
- Pascal M. Lavoie
- Division of Neonatology/Department of Pediatrics, University of British Columbia, Vancouver, Canada,Children’s and Women’s Health Centre of British Columbia, Vancouver, Canada
| | - Chandra Pham
- Children’s and Women’s Health Centre of British Columbia, Vancouver, Canada
| | - Kerry L. Jang
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
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Jegatheesan P, Ianus V, Buchh B, Yoon G, Chorne N, Ewig A, Lin E, Fields S, Moon-Grady A, Tacy T, Milstein J, Schreiber M, Padbury J, Clyman R. Increased indomethacin dosing for persistent patent ductus arteriosus in preterm infants: a multicenter, randomized, controlled trial. J Pediatr 2008; 153:183-9. [PMID: 18534218 DOI: 10.1016/j.jpeds.2008.01.031] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Revised: 12/19/2007] [Accepted: 01/24/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We conducted a multicenter, randomized, controlled trial to determine whether higher doses of indomethacin would improve the rate of patent ductus arteriosus (PDA) closure. STUDY DESIGN Infants (<28 weeks gestation) who received a conventional, prophylactic 3-dose course of indomethacin were eligible if they had continued evidence of persistent ductus patency on an echocardiogram obtained before the third prophylactic indomethacin dose. Infants (n = 105) were randomized to receive an extended 3-day course of either low-dose (0.1 mg/kg/d) or higher-dose (0.2 or 0.5 mg/kg/d) indomethacin. An echocardiogram was obtained 24 hours after the last dose of study drug. RESULTS Despite increasing serum indomethacin concentrations by 2.9-fold in the higher-dose group, we failed to detect a significant decrease in the rate of persistent PDA (low = 52%; higher = 45%, P = .50). The higher-dose group had a significantly higher occurrence of serum creatinine >2 mg/100 mL (low = 6%, higher = 19%, P < .05) and moderate/severe retinopathy of prematurity (ROP) (low = 15%, higher = 36%, P < .025). The incidence of moderate/severe ROP was directly related to the poststudy indomethacin concentrations (odds ratio = 1.75, confidence interval: 1.15-2.68, P < .01). CONCLUSION Increasing indomethacin concentrations above the levels achieved with a conventional dosing regimen had little effect on the rate of PDA closure but was associated with higher rates of moderate/severe ROP and renal compromise.
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Affiliation(s)
- Priya Jegatheesan
- Cardiovascular Research Institute and Department of Pediatrics, University of California, San Francisco, California 94143-0544, USA
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