Non-cardiogenic lung edema in a woman treated with atosiban for preterm labor

Atosiban-induced acute pulmonary edema: A rare but severe complication of tocolysis

Background

Atosiban is commonly used to delay premature labor in pregnant women and is thought to have few side effects.

Objectives

To report a case of acute pulmonary edema (APE) following administration of atosiban and conduct a systematic review to identify common characteristics and risk factors of atosiban-associated APE.

Methods

Searches were performed in Pubmed, Embase, and Web of Science using the keyword "Atosiban" combined with the terms "Pulmonary edema" or "Dyspnea" or "Hypoxia" on 9th July 2022. Only case reports of atosiban-associated APE were included without language restrictions. Data were extracted from the reports, and median, range, and percentages were calculated as applicable. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklist for case reports.

Results

Seven cases of atosiban-associated APE were included in the systematic review, including our case. APE occurred at a median gestational age of 32 + 6 weeks. Most patients were nulliparous (6/7, 85.7%) and were in multiple pregnancies (5/7, 71.4%). All patients were prescribed antenatal corticosteroids and tocolytics, with three (42.9%) receiving only atosiban and four (57.1%) receiving atosiban and other tocolytics. The median interval from starting atosiban administration to APE onset was about 40 h, and three patients (42.9%) showed symptoms 2-10 h after the end of atosiban treatment. Radiographic examinations (chest X-ray and/or computer tomography scan) confirmed APE in all patients and pleural effusion in four patients (57.1%). Five patients (71.4%) underwent emergency cesarean section, one patient (14.3%) with twin pregnancy had vaginal delivery with the help of suction cup and forceps, and another patient (14.3%) continued the pregnancy. All patients recovered well after administration of oxygen, diuresis, and other supportive therapy.

Conclusion

Atosiban may cause acute pulmonary edema in patients with underlying risk factors. This complication remains rare, but caution during tocolytic treatment using atosiban is recommended.

Non-Cardiogenic Pulmonary Edema Due to Administration of Atosiban

We report the case of a pregnant woman, treated with atosiban for premature labor, who developed non-cardiogenic pulmonary edema. She corresponded initially to oxygen supplementation and furosemide administration to induce diuresis but the onset of preterm contractions combined with aggravation of respiratory failure led the patient to a cesarean section, and subsequently to the intensive care unit where she remained intubated for 24 hours. In this case report, we emphasize the importance of distinguishing between two types of pulmonary edema: cardiogenic and non-cardiogenic. The instant separation between these two categories, most of the time with transthoracic echocardiography while the patient is on early support of ventilation, increases the optimum outcome for the patient.

Successful pregnancy in left ventricular hypertrabeculation/noncompaction with implanted cardioverter/defibrillator and a variant in the TPM1 Gen (c.425A > T) in mother and child

Pregnancy in left ventricular hypertrabeculation/noncompaction (LVHT) is a matter of concern due to the risk for arrhythmia or heart failure (HF). This risk seems higher if arrhythmias have been already diagnosed before pregnancy. Pregnancies in LVHT cases with implanted cardioverter-defibrillators (ICD) are rarely reported.We report pregnancy of and delivery to a 28-year old patient with hypertrophic phenotype of LVHT with ICD, implanted 11 years previously for secondary prevention of sudden cardiac death, in whom genetic analysis disclosed a variant in the TPM1 Gen (c.425A > T). Until the 28th gestational week (GW), the pregnancy was without problems, then increasing HF due to diastolic dysfunction developed. In GW34, she was treated with atosiban for tocolysis because of premature labor. Due to aggravation of HF, preterm delivery by cesarean section in spinal anesthesia in GW35 was carried out. Delivery and maternal postpartal course were without problems, HF regressed. ICD interrogation did not show any arrhythmia.Pregnancy and delivery can be managed safely in hypertrophic phenotype of LVHT with ICD under interdisciplinary surveillance. Diastolic dysfunction may occur in the third trimester and lead to HF. Tocolytic drugs should be used with caution, even though the drugs are assumed to be safe regarding cardiovascular complications.

Learning objective

Pregnancy and delivery can be managed safely in hypertrophic phenotype of left ventricular hypertrabeculation/noncompaction with implanted cardioverter-defibrillators under interdisciplinary surveillance. Diastolic dysfunction may occur in the third trimester and lead to heart failure. Tocolytic drugs should be used with caution, even though the drugs are assumed to be safe regarding cardiovascular complications.

Critical appraisal and clinical utility of atosiban in the management of preterm labor

Preterm birth is the major cause of perinatal morbidity and mortality in the developed world, and spontaneous preterm labor is the commonest cause of preterm birth. Interventions to treat women in spontaneous preterm labor have not reduced the incidence of preterm births but this may be due to increased risk factors, inclusion of births at the limits of viability, and an increase in the use of elective preterm birth. The role of antibiotics remains unproven. In the largest of the randomized controlled trials, evaluating the use of antibiotics for the prevention of preterm births in women in spontaneous preterm labor, antibiotics against anaerobes and bacterial vaginosis-related organisms were not included, and no objective evidence of abnormal genital tract flora was obtained. Atosiban and nifedipine are the main tocolytic agents used to treat women in spontaneous preterm labor, but atosiban is the tocolytic agent with the fewest maternal - fetal side effects. A well conducted randomized controlled trial comparing atosiban with nifedipine for their effectiveness and safety is needed.