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GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE
A Journal on Internal Medicine and Pharmacology
Indexed/Abstracted in: BIOSIS Previews, EMBASE, Scopus, Emerging Sources Citation Index
Gazzetta Medica Italiana Archivio per le Scienze Mediche 2006 June;165(3):109-13
Premature closure of the ductus arterious
Martino V. 1, Malvasi A. 2, Iliceto N. 1
1 Dipartimento di Ostetricia e Ginecologia, Casa di Cura "Santa Maria", Bari;
2 Unità Operativa di Terapia Intensiva Cardiochirurgica Pediatrica, Ospedale Giovanni XXIII, Bari
The ductus arteriosus link pulmonary trunk with aorta and it carry out the blood, in uterus, to by pass the lung circulation. The closure of the ductus irreversible and spontaneous in uterus it is possible but it is rare, because the closure is usually determined by drugs. In the fetus the closure of ductus begins with progressive constriction of the vessel walls, wich initially leads to very high flow velocities from the pulmunary trunk towards the descending aorta, wich can be measured on Doppler ultrasound. The non steroidal anti inflammatory drugs (NSAIDs) antagonaized the prostaglandines and promote the reduction of diameter inside of the ductus with the appearance inside the vassel of irregular thickness which progressively will closed the vassel. The most widley described drug that can lead to ductal constriction is indomethacin. If it is administred for more time to the mother, in the second half of pregnancy, with the others non steroidal anti inflammatory drugs (NSAIDs), like acetilsalicilic acid, diclofenac and nimesulide it can determine the constriction or the early, intempestive and, in some cases irreversible, closure of ductus. The betamethasone, applied to enhance fetal lung maturation, can cause transient reversible ductal constriction. In utero closure of the fetal ductus arterious or of forame ovale can occur spontaneously or caused by pharmacological agents. It can deterime immediately in post birth newborn cardiac failure. In the case of severe constriction of the ductus arteriosus it don’t link more right ventricle and pulmonary trunk with aorta descending so a much more volume of blood it will come to pulmunary atreries determining pulmunary hypertension. The closure of ductus can determine dilatation of right ventricule and significant tricuspid regurgitation, with fetal hidrope and subseguent fetal death. The closure and constriction can better detected with ultrasound. It appear with dilatation of rigth ventricle and significant tricuspid regurgitation. This situation can it be association with abnormal flow in venous ductus that probe existatant of cardiac failure in the fetus. In this case it is necessary an urgent cesarean section. However in some fetus affected by occlusion of ductus it is possible a close monitoring with echocardography and so the pregnancy could be prolonged until fetal lung maturation. Indeed most fetuses affected by ductal occlusion there is a redistribution of flw through the forame ovale and do not develope hydrops, and resolution of ductal constriction may occur.
Other possible neonatal and fetal complications are pulmonary hypertension, oligohyrdamnios, hiperbilirubinemia, enterocolitys necrosys and intraventricular hemorragies. The indomethacin treatment as tocolytics before 32 weeks of gestation is accepted, but the NSAIDs for pain relife are best avoided in the third trimester of pregnancy. Because of their easy transplacental transfer, their unpredictable pharmacodynamics in the fetus, and their often very profund effect on ductal costriction late in pregnancy they can have highly detrimental effacts on the fetus and the neonate.