Prenatal Constriction of the Fetal Ductus Arteriosus - Related to Maternal Pain Medication?

Use of dipyrone during pregnancy and risk of congenital anomalies: a systematic review

PURPOSE

This study aimed to summarize the evidence on the teratogenic effects of dipyrone used during pregnancy.

METHODS

Databases (MEDLINE, EMBASE, Cochrane Library, CINAHL, Web of Science, Lilacs, SciELO, SCOPUS, OasisBR, and OpenGray) were reviewed until September 2023. We included studies that compared pregnant women who used dipyrone during any gestational period with those who used other analgesics or did not use any analgesics during the same gestational period. The outcome assessed was the presence of any congenital anomaly. Two reviewers independently conducted the review process, and a third reviewer resolved any disagreements. The risk of bias was assessed using the Joanna Briggs Institute tool for observational studies. The reviewed data synthesis is presented in narrative form.

RESULTS

The search retrieved 2045 results, of which seven studies were included in the review, four were case‒control studies, and three were cohort studies involving 153,562 participants. The congenital anomalies evaluated varied across studies, with unspecified congenital anomalies predominating. Five of seven studies found no association between dipyrone and congenital anomalies. In a case‒control study, a positive association was found between dipyrone use and isolated congenital cataracts compared to two control groups; in another study, a positive association for unspecified congenital anomalies was observed in only one of the two control groups analyzed. In all studies, a high risk of bias was identified, especially regarding measuring the exposure, outcome, and assessment of confounding factors.

CONCLUSION

There is not enough evidence to define the risk of congenital anomalies associated with dipyrone use during pregnancy.

REGISTRATION

CRD 42022333041.

Efficacy and Safety of Aspirin 162 mg for Preeclampsia Prophylaxis in High-Risk Patients

OBJECTIVE

The aim of this study was to compare the safety and efficacy of aspirin 162 mg to the standard recommended dose of 81 mg for preeclampsia prevention.

STUDY DESIGN

A retrospective cohort study of patients at risk for preeclampsia who delivered between January 2013 and December 2020 at Henry Ford Health was performed. Patients were divided into three groups: a no aspirin group, a group treated under an 81 mg aspirin preeclampsia prophylaxis protocol, and a group treated under a 162 mg protocol. Univariate and multivariable logistic regression analyses compared rates of preeclampsia and secondary outcomes between groups. Clinical side effects traditionally associated with aspirin use were also assessed.

RESULTS

Of 3,597 patients, 2,266 (63%) were in the no aspirin group, 944 (26%) were in the 81 mg group, and 387 (11%) were in the 162 mg group. The rate of preeclampsia was significantly lower in the 162 mg group (10.1%, odds ratio, 0.68; 95% confidence interval, 0.46-0.99) compared with the 81 mg group (14.2%). The rate of preeclampsia was identical in the no aspirin and 81 mg groups. The rate for postpartum hemorrhage, postpartum hematoma, and intraventricular hemorrhage of the newborn were not significantly different between patients in the 162 and 81 mg groups.

CONCLUSION

We observed a significantly lower rate of preeclampsia in high-risk patients who were treated with the 162 mg dose of aspirin for preeclampsia prophylaxis, and bleeding complications were not seen with the higher dose. Our study suggests that aspirin 162 mg may be considered for prophylaxis in patients at high risk for preeclampsia.

KEY POINTS

· Aspirin 81 mg is currently standard for preeclampsia prophylaxis.. · Preeclampsia rate is significantly lower among high-risk patients taking aspirin 162 mg compared with 81 mg.. · Bleeding complications are not increased among those taking aspirin 162 mg..

Low-Dose Aspirin after ASPRE-More Questions Than Answers? Current International Approach after PE Screening in the First Trimester

Preeclampsia (PE) is a multi-factorial disorder of pregnancy, and it continues to be one of the leading causes of fetal and maternal morbidity and mortality worldwide. Aspirin is universally recommended for high-risk women to reduce preeclampsia risk. The purpose of this review is to summarize the recommendations of various scientific societies on predicting preeclampsia and their indications for the inclusion of acetylsalicylic acid (ASA) prophylaxis. Fourteen guidelines were compared. The recommended dose, screening method, and gestational age at the start of the test vary depending on the recommendation. The societies are inclined to recommend using increasingly higher doses (>75 mg) of ASA, with many encouraging doses from 100 mg upward. Most societies indicate that the optimal time for implementing aspirin is prior to 16 weeks' gestation. Following the publication of the Aspirin for Evidence-Based Preeclampsia Prevention (ASPRE) trial results and other papers evaluating the Fetal Medicine Foundation (FMF) screening model, a large number of societies have changed their recommendations from those based on risk factors alone to the ones based on the risk assessment proposed by the FMF. This allows for the detection of a high-risk pregnancy population in whom aspirin will be remarkably effective in preventing preterm PE, thereby decreasing maternal and fetal morbidity.

Prevention of preeclampsia with aspirin

Preeclampsia is defined as hypertension arising after 20 weeks of gestational age with proteinuria or other signs of end-organ damage and is an important cause of maternal and perinatal morbidity and mortality, particularly when of early onset. Although a significant amount of research has been dedicated in identifying preventive measures for preeclampsia, the incidence of the condition has been relatively unchanged in the last decades. This could be attributed to the fact that the underlying pathophysiology of preeclampsia is not entirely understood. There is increasing evidence suggesting that suboptimal trophoblastic invasion leads to an imbalance of angiogenic and antiangiogenic proteins, ultimately causing widespread inflammation and endothelial damage, increased platelet aggregation, and thrombotic events with placental infarcts. Aspirin at doses below 300 mg selectively and irreversibly inactivates the cyclooxygenase-1 enzyme, suppressing the production of prostaglandins and thromboxane and inhibiting inflammation and platelet aggregation. Such an effect has led to the hypothesis that aspirin could be useful for preventing preeclampsia. The first possible link between the use of aspirin and the prevention of preeclampsia was suggested by a case report published in 1978, followed by the first randomized controlled trial published in 1985. Since then, numerous randomized trials have been published, reporting the safety of the use of aspirin in pregnancy and the inconsistent effects of aspirin on the rates of preeclampsia. These inconsistencies, however, can be largely explained by a high degree of heterogeneity regarding the selection of trial participants, baseline risk of the included women, dosage of aspirin, gestational age of prophylaxis initiation, and preeclampsia definition. An individual patient data meta-analysis has indicated a modest 10% reduction in preeclampsia rates with the use of aspirin, but later meta-analyses of aggregate data have revealed a dose-response effect of aspirin on preeclampsia rates, which is maximized when the medication is initiated before 16 weeks of gestational age. Recently, the Aspirin for Evidence-Based Preeclampsia Prevention trial has revealed that aspirin at a daily dosage of 150 mg, initiated before 16 weeks of gestational age, and given at night to a high-risk population, identified by a combined first trimester screening test, reduces the incidence of preterm preeclampsia by 62%. A secondary analysis of the Aspirin for Evidence-Based Preeclampsia Prevention trial data also indicated a reduction in the length of stay in the neonatal intensive care unit by 68% compared with placebo, mainly because of a reduction in births before 32 weeks of gestational age with preeclampsia. The beneficial effect of aspirin has been found to be similar in subgroups according to different maternal characteristics, except for the presence of chronic hypertension, where no beneficial effect is evident. In addition, the effect size of aspirin has been found to be more pronounced in women with good compliance to treatment. In general, randomized trials are underpowered to investigate the treatment effect of aspirin on the rates of other placental-associated adverse outcomes such as fetal growth restriction and stillbirth. This article summarizes the evidence around aspirin for the prevention of preeclampsia and its complications.

Molecular and Mechanical Mechanisms Regulating Ductus Arteriosus Closure in Preterm Infants

Failure of ductus arteriosus closure after preterm birth is associated with significant morbidities. Ductal closure requires and is regulated by a complex interplay of molecular and mechanical mechanisms with underlying genetic factors. In utero patency of the ductus is maintained by low oxygen tension, high levels of prostaglandins, nitric oxide and carbon monoxide. After birth, ductal closure occurs first by functional closure, followed by anatomical remodeling. High oxygen tension and decreased prostaglandin levels mediated by numerous factors including potassium channels, endothelin-1, isoprostanes lead to the contraction of the ductus. Bradykinin and corticosteroids also induce ductal constriction by attenuating the sensitivity of the ductus to PGE2. Smooth muscle cells of the ductus can sense oxygen through a mitochondrial network by the role of Rho-kinase pathway which ends up with increased intracellular calcium levels and contraction of myosin light chains. Anatomical closure of the ductus is also complex with various mechanisms such as migration and proliferation of smooth muscle cells, extracellular matrix production, endothelial cell proliferation which mediate cushion formation with the interaction of blood cells. Regulation of vessel walls is affected by retinoic acid, TGF-β1, notch signaling, hyaluronan, fibronectin, chondroitin sulfate, elastin, and vascular endothelial cell growth factor (VEGF). Formation of the platelet plug facilitates luminal remodeling by the obstruction of the constricted ductal lumen. Vasa vasorum are more pronounced in the term ductus but are less active in the preterm ductus. More than 100 genes are effective in the prostaglandin pathway or in vascular smooth muscle development and structure may affect the patency of ductus. Hemodynamic changes after birth including fluid load and flow characteristics as well as shear forces within the ductus also stimulate closure. Current pharmacological treatment for the closure of a patent ductus is based on the blockage of the prostaglandin pathway mainly through COX or POX inhibition, albeit with some limitations and side effects. Further research for new agents aiming ductal closure should focus on a clear understanding of vascular biology of the ductus.

Aspirin for prevention of preeclampsia and fetal growth restriction

For the past decades, growing attention has been given to aspirin use during pregnancy. It favors placentation by its proangiogenic, antithrombotic, and anti-inflammatory effects. Therefore, low doses of aspirin are prescribed in the prevention of placenta-mediated complications, mainly preeclampsia and fetal growth restriction. However, questions regarding its clinical application are still debated. Aspirin is effective in preventing preeclampsia in a high-risk population. Most guidelines recommend that risk stratification should rely on medical history. Nevertheless, screening performances dramatically improve if biochemical and biophysical markers are included. Concerning the appropriate timing and dose, latest studies suggest aspirin should be started before 16 weeks of pregnancy and at a daily dose of 100 mg or more. Further studies are needed to improve the identification of patients likely to benefit from prophylactic aspirin. Besides, the role of aspirin in the prevention of fetal growth restriction is still questioned.

Low dose aspirin for preventing fetal growth restriction: a randomised trial

The purpose of this study was to investigate when in pregnancy to stop the administration of low dose aspirin (150 mg/daily) so as to prevent fetal growth restriction (FGR) A randomised, placebo-controlled study was designed. The patients were all screened positive using the Fetal Medicine Foundation (FMF) early pregnancy screening test for preeclampsia (PE) and FGR prediction. One hundred and fifty patients were enrolled and divided equally into three groups: A – the controls who received placebo treatment; B – those who received aspirin till 32 weeks of gestation and C – those who received aspirin till 36 weeks of gestation. The mean gestational age at enrollment was similar for all the groups (12.4 weeks). The growth curves, fetal and maternal Doppler measurements and amniotic fluid index (AFI) were monitored every 4 weeks. Also, the outcome of the pregnancy was noted and all the results were compared between the groups. FGR was defined as a fetal weight below the 10th centile for gestational age. In group C, there were less cases of FGR compared with the other groups: 6% vs. 10% in group B vs. 24% in controls. Also, there was a significant birth weight improvement in this group with a median of 3180 g compared with 2950 g in group B and 2760 g in group A (P=0.01). The gestational age at delivery was similar in all the groups (39 weeks in group C/39.2 weeks in group B/38.6 weeks in group A). In conclusion, low dose aspirin improves the outcome in the selected population and should be offered for prevention of FGR from 12 to 36 weeks.

Prediction and prevention of pre-eclampsia in Asian subpopulation

The benefit of the early administration of aspirin to reduce preterm pre-eclampsia among screened positive European women from multivariate algorithmic approach (ASPRE trial) has opened an intense debate on the feasibility of universal screening. This review aims to assess the new perspectives in the combined screening of pre-eclampsia in the first trimester of pregnancy and the chances for prevention using low-dose aspirin with special emphasis on the particularities of the Asian population. PubMed, CENTRAL and Embase databases were searched from inception until 15 November 2017 using combinations of the search terms: preeclampsia, Asian, prenatal screening, early prediction, ultrasonography, pregnancy, biomarker, mean arterial pressure, soluble fms-like tyrosine kinase-1, placental growth factor, pregnancy-associated plasma protein-A and pulsatility index. This is not a systematic review or meta-analysis, so the risk of bias of the selected published articles and heterogeneity among the studies need to be considered. The prevalence of pre-eclampsia and serum levels of biochemical markers in Asian are different from Caucasian women; hence, Asian ethnicity needs to be corrected for in the algorithmic assessment of multiple variables to improve the screening performance. Aspirin prophylaxis may still be viable in Asian women, but resource implication needs to be considered. Asian ethnicity should be taken into account before implementing pre-eclampsia screening strategies in the region. The variables included can be mixed and matched to achieve an optimal performance that is appropriate for economical restriction in individual countries.

Aspirin for Prevention of Preeclampsia

Aspirin is currently the most widely prescribed treatment in the prevention of cardiovascular complications. The indications for the use of aspirin during pregnancy are, however, the subject of much controversy. Since the first evidence of the obstetric efficacy of aspirin in 1985, numerous studies have tried to determine the effect of low-dose aspirin on the incidence of preeclampsia, with very controversial results. Large meta-analyses including individual patient data have demonstrated that aspirin is effective in preventing preeclampsia in high-risk patients, mainly those with a history of preeclampsia. However, guidelines regarding the usage of aspirin to prevent preeclampsia differ considerably from one country to another. Screening modalities, target population, and aspirin dosage are still a matter of debate. In this review, we report the pharmacodynamics of aspirin, its main effects according to dosage and gestational age, and the evidence-based indications for primary and secondary prevention of preeclampsia.

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

BACKGROUND

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

RESULTS

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

CONCLUSIONS

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

[For a targeted use of aspirin]

The use of low-dose aspirin in pregnancy should remain a highly targeted indication since its long-term safety has not been established and should be restricted to women at high risk of vascular complications. Indications for which the benefit of aspirin has been shown are women with a history of preeclampsia responsible for a premature birth before 34 weeks, those having at least two history of preeclampsia, those with an antiphospholipid syndrome and those with lupus associated with positive antiphospholipid antibodies or renal failure. In all other cases, the level of evidence of the benefit of aspirin is insufficient to recommend its routine prescription.

Should we recommend universal aspirin for all pregnant women?

Low-dose aspirin has been demonstrated to reduce the incidence of preeclampsia and fetal growth restriction in at-risk populations. Its role in low-risk populations is as yet unknown. Novel preeclampsia screening tests are emerging that can predict the risk of the development of preeclampsia from as early as 11 weeks of gestation. It may be more efficacious, acceptable, and cost-effective to prescribe low-dose aspirin to all pregnant women from the first trimester as opposed to performing a screening test in the first instance. There is variation in opinion: the American College of Obstetricians and Gynecologists suggests the use of aspirin only in women who are at risk of preeclampsia, based on patient history; the National Institute for Health and Clinical Excellence, UK, and the US Preventative Services Task Force recommend the use of low-dose aspirin if there is 1 major or 2 moderate risk factors. This point-counterpoint discussion shall address (1) controversies regarding the real impact of low-dose aspirin; (2) controversies in the actual guidelines among the different national societies; (3) controversies regarding emerging preeclampsia screening tests in terms of cost-effectiveness and efficacy, and (4) points in favor of the provision of universal vs screened-positive women.

Study protocol for the randomised controlled trial: combined multimarker screening and randomised patient treatment with ASpirin for evidence-based PREeclampsia prevention (ASPRE)

INTRODUCTION

Pre-eclampsia (PE) affects 2-3% of all pregnancies and is a major cause of maternal and perinatal morbidity and mortality. Prophylactic use of low-dose aspirin in women at risk for PE may substantially reduce the prevalence of the disease. Effective screening for PE requiring delivery before 37 weeks (preterm PE) can be provided by a combination of maternal factors, uterine artery Doppler, mean arterial pressure, maternal serum pregnancy-associated plasma protein A and placental growth factor at 11-13 weeks' gestation, with a detection rate of 75% at a false-positive rate of 10%. We present a protocol (V.6, date 25 January 2016) for the ASpirin for evidence-based PREeclampsia prevention (ASPRE) trial, which is a double-blinded, placebo-controlled, randomised controlled trial (RCT) that uses an effective PE screening programme to determine whether low-dose aspirin given to women from 11 to 13 weeks' gestation will reduce the incidence of preterm PE.

METHODS AND ANALYSIS

All eligible women attending for their first trimester scan will be invited to participate in the screening study for preterm PE. Those found to be at high risk of developing preterm PE will be invited to participate in the RCT. Further scans will be conducted for assessment of fetal growth and biomarkers. Pregnancy and neonatal outcomes will be collected and analysed. The first enrolment for the pilot study was in April 2014. As of April 2016, 26 670 women have been screened and 1760 recruited to the RCT. The study is registered on the International Standard Randomised Controlled Trial Number (ISRCTN) registry.

TRIAL REGISTRATION NUMBER

ISRCTN13633058.

Prenatal effects of maternal consumption of polyphenol-rich foods in late pregnancy upon fetal ductus arteriosus

Fetal circulation has characteristic features, being morphologically and functionally different from extrauterine circulation. The ductus arteriosus plays a fundamental role in directing the blood flow to fetal inferior body parts. Basically, the ductus arteriosus directs 80-85% of the right ventricular output arising from the superior vena cava, coronary sinus, and a small part from the inferior vena cava to descending aorta. Its histological structure is made up predominantly by a thick muscular layer, differently from the aorta and the pulmonary artery, which increases with gestational age. The fibers have a circumferential orientation, especially at the external layers, facilitating and making effective ductal constriction. These factors may generate lumen alterations which may cause fetal and neonatal complications, such as heart failure, hydrops, neonatal pulmonary hypertension, and even death. Classically, maternal administration of indomethacin and/or other antiinflammatory drugs interfere in prostaglandins metabolism, causing ductal constriction. However, many cases of fetal ductal constriction, as well as of persistent neonatal pulmonary artery hypertension, remain without an established etiology, being referred as "idiopathic." In recent years, a growing body of evidence has shown that herbs, fruits, nuts, and a wide diversity of substances commonly used in daily diets have definitive effects upon the metabolic pathway of inflammation, with consequent inhibition of prostaglandins synthesis. This antiinflammatory action, especially of polyphenols, when ingested during the third trimester of pregnancy, may influence the dynamics of fetal ductus arteriosus flow. The goal of this review is to present these new observations and findings, which may influence dietary orientation during pregnancy.

[Questionnaire survey about NSAIDs use in late pregnancy for pharmacists and physicians]

It has been reported the use of nonsteroid anti-inflammatory drugs (NSAIDs) in late pregnancy was associated with potentially fetal toxicity (contraction of fetal ductus areteriosus). According to the package inserts in Japan, many oral NSAIDs are contraindicated to women in late pregnancy, but several oral and topical NSAIDs with case reports of fetal toxicity are not. In the present study, a web-based questionnaire survey was conducted in pharmacists/physicians to determine their awareness of fetal toxicity caused by NSAIDs, as well as their attitudes regarding the use of NSAIDs in late pregnancy. Responses were obtained from 427 pharmacists, 22 obstetricians, and 160 non-obstetric physicians. Of the non-obstetric respondents, more than 40% had no knowledge of fetal ductus arteriosus contraction caused by oral ibuprofen, and most of them were not aware of the relevant warning statement on the package insert. In contrast, these were familiar to nearly 100% of the obstetricians. As for ketoprofen tape, only 20-40% of the pharmacists/physicians were aware of the warning statement, and nearly all respondents did not confirm whether the patient was in late pregnancy. The majority of the respondents answered that oral ibuprofen, ketoprofen tape and NSAID-containing OTC drugs should not be used in late pregnancy after they knew the warning statements in late pregnancy. This survey suggests that the fetal toxicity of NSAIDs is not well recognized by pharmacists/physicians. It would be necessary to make it thoroughly known to them through such as enrichment of safety information on the package inserts, accompanying with the evidence.

Low-dose aspirin for prevention of adverse outcomes related to abnormal placentation

Meta-analysis of randomized studies on the use of low-dose aspirin in women at high risk of preeclampsia (PE) has demonstrated that if treatment is initiated at ≤16 weeks' gestation, there is significant reduction in the risk of PE [relative risk (RR) 0.47, 95% confidence interval (CI) 0.36-0.62], fetal growth restriction (RR 0.46, 95% CI 0.33-0.64), preterm birth (RR 0.35, 95% CI 0.22-0.57) and perinatal death (RR 0.41, 95% CI 0.19-0.92), whereas the effect of treatment after 16 weeks is substantially less (RR 0.78, 95% CI 0.61-0.99; RR 0.98, 95% CI 0.88-1.08; RR 0.90, 95% CI 0.83-0.97; and RR 0.93, 95% CI 0.73-1.19, respectively). Moreover, the decrease in the risk of PE from early onset treatment seems to be related to the dose of aspirin, and a dose of >80 mg daily should be considered for optimal benefits.

ASPIRIN ADMINISTRATION FOR PREVENTION OF ADVERSE PREGNANCY OUTCOMES

The prophylactic use of low-dose aspirin for prevention of preeclampsia has been an important research question in obstetrics for the last three decades. In 1979, Crandon and Isherwood observed that nulliparous women who had taken aspirin regularly during pregnancy were less likely to have preeclampsia than women who did not. In 1985, Beaufils et al published the first randomized trial suggesting that 150 mg aspirin and 300 mg dipyridamole daily from 3 months’ gestation onwards decreased the risk of preeclampsia, fetal growth restriction and stillbirth in high-risk women. Subsequently, more than 50 trials have been carried out throughout the world and a meta-analysis of these studies reported that the administration of low-dose aspirin in high-risk pregnancies is associated with a decrease in the rate of preeclampsia by approximately 10%. Consequently, several national professional bodies recommend that high-risk pregnancies should be treated with aspirin (50–150 mg daily).

A consensus approach to the classification of pediatric pulmonary hypertensive vascular disease: Report from the PVRI Pediatric Taskforce, Panama 2011

Current classifications of pulmonary hypertension have contributed a great deal to our understanding of pulmonary vascular disease, facilitated drug trials, and improved our understanding of congenital heart disease in adult survivors. However, these classifications are not applicable readily to pediatric disease. The classification system that we propose is based firmly in clinical practice. The specific aims of this new system are to improve diagnostic strategies, to promote appropriate clinical investigation, to improve our understanding of disease pathogenesis, physiology and epidemiology, and to guide the development of human disease models in laboratory and animal studies. It should be also an educational resource. We emphasize the concepts of perinatal maladaptation, maldevelopment and pulmonary hypoplasia as causative factors in pediatric pulmonary hypertension. We highlight the importance of genetic, chromosomal and multiple congenital malformation syndromes in the presentation of pediatric pulmonary hypertension. We divide pediatric pulmonary hypertensive vascular disease into 10 broad categories.

Spontaneous prenatal ductal closure: postnatal diagnosis?

Prenatal ductal constriction and closure usually are related to maternal intake of prostaglandin receptor inhibitors during late gestation but may occur spontaneously. This report describes three live-born infants sharing echocardiographic features of spontaneous intrauterine ductal constriction, closure, or both, although only one had a prenatal diagnosis. Interestingly, in addition to severely hypertrophied right ventricles, all three had hyperechogenic tricuspid valve papillary muscles. Two also had mild ascending aorta dilation. These cases raise mechanistic questions because of intrauterine ductal occlusion, bright papillary muscles, and potential dilated ascending aortas.

[Persistent pulmonary hypertension of the newborn following ingestion of nonsteroidal anti-inflammatory drugs during pregnancy]

Nonsteroidal anti-inflammatory drugs induce the inhibition of prostaglandin synthesis, which can cause constriction of the fetal ductus arteriosus in the pregnancy. We report two cases of antenatal closure of ductus arteriosus with severe pulmonary hypertension following maternal ingestion of nonsteroidal anti-inflammatory drugs (niflumic acid and acetylsalicylic acid) in the last days before delivery. To our knowledge, this is only the second case in literature describing antenatal closure of ductus arteriosus after the administration of niflúmic acid. Prescription of nonsteroidal anti-inflammatory drugs must be avoided during pregnancy. Fetal echocardiography must be monitored in those women treated with nonsteroidal anti-inflammatory drugs.