It can take 10 days for the right fetal ventricle to recover after a temporary closure of the ductus arteriosus

It can take 10 days for the right fetal ventricle to recover after a temporary closure of the ductus arteriosus
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  Letters to the Editor  349 Figure 3  Three-dimensional reconstruction of the fetal heart usinginversion mode in a normal fetus at 25 weeks of gestation. Theaorta (Ao) arose from the left ventricle and pulmonary artery (PA)left from the right ventricle. AoA, aortic arch; DAo, descendingaorta. of the more easily distinguishable boundaries between thecavities 9 .Comparedtoother3Dand4Dtechniques,theinversionmode has been shown to be superior to power Dopplerin image quality, but it provides less information aboutneighboring tissue than does the glass body mode 8 . Itcan be used to display any fluid-containing structure, butit lacks information on velocity or direction of bloodflow. Moreover, fetal movements may affect renderingand artifacts can be encountered. More studies on thecomparative performance and more efforts to overcomethe limitations of these new methods in prenataldiagnosisare needed.S.-Y. Dai, E. Inubashiri, U. Hanaoka, K. Kanenishi,C. Yamashiro, H. Tanaka, T. Yanagihara and T. Hata* Department of Perinatology and Gynecology,Kagawa University School of Medicine, 1750-1 Ikenobe,Miki, Kagawa 761-0793, Japan*Correspondence.(e-mail: DOI:  10.1002/uog.2855 References 1. Tometzki AJ, Suda K, Kohl T, Kovalchin JP, Silverman NH.Accuracy of prenatal echocardiographic diagnosis and prognosisof fetuses with conotruncal anomalies.  J Am Coll Cardiol   1999; 33 : 1696–1701.2. Smith RS,Comstock CH,Kirk JS,Lee W,Riggs T,Weinhouse E.Double-outlet right ventricle: an antenatal diagnostic dilemma. Ultrasound Obstet Gynecol   1999;  14 : 315–319.3. Goncalves LF, Espinoza J, Lee W, Mazor M, Romero R. Three-and four-dimensional reconstruction of the aortic and ductalarches using inversion mode: a new rendering algorithm forvisualization of fluid-filled anatomical structures.  Ultrasound Obstet Gynecol   2004;  24 : 696–698.4. Lee W, Goncalves LF, Espinoza J, Romero R. Inversion mode:a new volume analysis tool for 3-dimensional ultrasonography.  J Ultrasound Med   2005;  24 : 201–207.5. Goncalves LF, Espinoza J, Lee W, Nien JK, Hong JS, Santolaya-Forgas J, Mazor M, Romero R. A new approach to fetalechocardiography: digital casts of the fetal cardiac chambersand great vessels for detection of congenital heart disease.  J Ultrasound Med   2005;  24 : 415–424.6. Espinoza J, Goncalves LF, Lee W, Mazor M, Romero R. Anovel method to improve prenatal diagnosis of abnormalsystemic venous connections using three- and four-dimensionalultrasonography and ‘inversion mode’.  Ultrasound Obstet Gynecol   2005;  25 : 428–434.7. Ghi T, Cera E, Segata M, Michelacci L, Pilu G, Pelusi G. Inver-sion mode spatio-temporal image correlation (STIC) echocardio-graphy in three-dimensional rendering of fetal ventricular septaldefects.  Ultrasound Obstet Gynecol   2005;  26 : 679–680.8. Chaoui R, Heling KS. New developments in fetal heart scanning:three- and four-dimensional fetal echocardiography.  Semin Fetal Neonatal Med   2005;  10 : 567–577.9. Deng J, Rodeck CH. New fetal cardiac imaging techniques. Prenat Diagn  2004;  24 : 1092–1103. SUPPLEMENTARY MATERIAL ONTHE INTERNET The following material is available from the Journalhomepage: 0960-7692/suppmat (restricted access) Videoclip S1  Three-dimensional imaging in theinversionmodedemonstratingthepulmonaryarteryand aorta arising in parallel from the right ventricleof a fetus with double-outlet right ventricle. It can take 10 days for the right fetal ventricle torecover after a temporary closure of the ductusarteriosus Non-steroidalanti-inflammatorydrug(NSAID)treatmentis known to cause premature closure of the fetalductus arteriosus. The frequency of closure is dependenton gestational age, dose and length of treatment 1 , 2 .Characteristic echocardiographic findings during closureof the ductus arteriosus include dilatation of the rightventricle with decreased fractional shortening duringsystole, and tricuspid regurgitation (TR). Blood flowvelocity in the ductus is also increased, with a pulsatilityindex of less than 1.90 2 . A case of normalization of fetal echocardiographic parameters following cessation of maternal use of NSAIDs is reported.Apregnantwomanat31 weeks’gestationwasadmittedfor inpatient care due to left-sided flank pain. Shehad no fever. Examination of her urine showed signsof blood on dipstick testing. The clinical diagnosison admission was kidney stones, and she was startedon hydromorphone–atropine sulfate (Dilaudid ® ) withgood effect. Ultrasound examination the following day Copyright © 2006 ISUOG. Published by John Wiley & Sons, Ltd.  Ultrasound Obstet Gynecol   2006;  28 : 345–351.  350  Letters to the Editor Figure 1  Blood flow velocity waveforms in the ductus arteriosusduring vessel constriction (a), and at 3 days (b) and 10 days(c) following cessation of maternal non-steroidal anti-inflammatorydrug treatment. Normal blood flow velocity is seen in (b) and (c). revealed a calcareous stone in the left renal pelvis withan average diameter of 4 cm. Moderate hydronephrosiswas seen on the right side. After 3 days in the wardher symptoms became worse and NSAID administrationwas discussed. We opted to try the woman on sulindactablets (Clinoril ® ) 200 mg twice daily because the risk of closure of the fetal ductus arteriosus has been reportedto be lower than that for diclofenac (Voltaren ® ) 3 . Duringthe following 7 days on treatment, there were no signsof constriction of the ductus arteriosus, but because of worsening of the patient’s condition two rectal dosesof 100 mg diclofenac were administered. The followingday a fetal ultrasound examination revealed signs of severe constriction of the ductus arteriosus with veryhigh velocities in the ductus (Figure 1) and a dilatedright ventriclewithdecreasedfractionalshortening(15%)and TR (Figure 2). The NSAID treatment was stopped,but hydromorphone–atropine sulfate treatment wasmaintained.Atthefirstfollow-upultrasoundexamination3daysafterdiscontinuingNSAIDtreatment,bloodflowintheductushadbecomenormal.TRpersistedandtherewasstill decreased fractional shortening of the right ventricleduring systole (21%). TR was still present 6 days fromdiscontinuingtreatment,butthefractionalshorteninghadbecome normal (28%). After 10 days without treatmentthe TR had disappeared.Three days later, at 34 weeks’ gestation, a Cesareansection was performed and a girl weighing 2115 g, withnormal Apgar scores and normal umbilical cord pH, wasdelivered. The baby was admitted for neonatal intensivecare without complications. The mother was discharged Figure 2  (a) Pansystolic tricuspid valve regurgitation at the time of the diagnosis of ductal constriction. Valve blood flow at 3 (b) 6(c) and 10 (d) days after discontinuing non-steroidalanti-inflammatory drug treatment. Normal valve blood flowvelocity was recorded for the first time 10 days after discontinuingtreatment (d). 8 days later in good condition. The calcareous kidneystone in the left renal pelvis was later successfully treatednon-invasively by ultrasound. At a follow-up visit 2months later the patient was feeling well and was withoutsymptoms.The present case illustrates clearly the typical ultra-sound findings during drug-induced constriction of thefetal ductus arteriosus. The follow-up examination alsodemonstrates a delay in recovery of right cardiac ventriclefunction, with normal function resuming after 10 dayswithout NSAID treatment. The present case also empha-sizes the need to restrict the use of NSAIDs during thesecond half of pregnancy. Whether this will affect long-term myocardial performance is unknown.S. Gudmundsson, Department of Obstetrics and Gynecology,Malm¨ o University Hospital, S – 205 02 Malm¨ o, Sweden*Correspondence.(e-mail: DOI:  10.1002/uog.3802Copyright © 2006 ISUOG. Published by John Wiley & Sons, Ltd.  Ultrasound Obstet Gynecol   2006;  28 : 345–351.  Letters to the Editor  351 References 1. Moise KJ, Huhta JC, Sharif DS, Ou Ch N, Kirshon B, Wasser-strum N, Cano L. Indomethacin in the treatment of prematurelabor. Effects on the fetal ductus arteriosus.  N Engl J Med   1988; 319 : 327–331.2. Tulzer G, Gudmundsson S, Tews G, Wood D, Cohen AW,Huhta JC. Incidence of indomethacin-induced human fetalductal constriction.  J Maternal Fetal Invest   1992;  1 :267–269.3. R¨as¨anen J, Jouppila P. Fetal cardiac function and ductusarteriosus during indomethacin and sulindac therapy forthreatened preterm labor: a randomized study.  Am J Obstet Gynecol   1995;  173 : 20–25.Copyright © 2006 ISUOG. Published by John Wiley & Sons, Ltd.  Ultrasound Obstet Gynecol   2006;  28 : 345–351.
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