Her growth was initially slow, however, by the age of five, she has maintained normal physical and mental growth. Unauthorized use of these marks is strictly prohibited. We share our experience in adjusting the dose and duration of indomethacin in the treatment of a patient who presented with severe polyhydramnios associated with antenatal BS. On the second day postpartum, the investigations showed elevated neonatal serum aldosterone at 12,500 ng/l (Reference range 3090 ng/l), and serum renin at 255.7 ng/ml/h (Reference range 237 ng/ml/h). Without such suggestive history, the diagnosis of antenatal BS requires a high index of suspicion since it remains a rare antenatal condition (14). Inclusion in an NLM database does not imply endorsement of, or agreement with, In the present report, the effect of indomethacin on fetal DA diameter was well-observed and rapid but reversible as seen when the dose was reduced and then when indomethacin was stopped at 32 weeks. Amniotic fluid index. Al Shibli A, Narchi H. Bartter and gitelman syndromes: spectrum of clinical manifestations caused by different mutations. It is still possible that if indomethacin was not given in the second pregnancy, the severity of polyhydramnios could have led to a much earlier delivery. Skip to content Care at Mayo Clinic Care at Mayo Clinic About Mayo Clinic Request Appointment Find a Doctor Clinical Trials Fetal Diag Ther. Am J Obst Gynecol. Bhat YR, Vinayaka G, Vani R, Prashanth KA, Sreelakshmi K. Antenatal bartter syndrome: a rare cause of unexplained severe polyhydramnios. National Library of Medicine Following delivery, women should receive adequate counseling about the specific care of the neonate and treatment options, which best be provided by a pediatric nephrologist. Srikumar S, Debnath J, Ravikumar R, Bandhu HC, Maurya VK. Investigations to exclude other causes of polyhydramnios, including complete blood count, Parvovirus IgG, and IgM antibodies, and oral glucose tolerance test were all normal. 610, 1314 (1987). Due to the risk of fetal heart problems, your baby's heart may need to be monitored with a fetal echocardiogram and Doppler ultrasound. Figure 4. Matsunoshita N, Nozu K, Shono A, Nozu Y, Fu XJ, Morisada N, et al.. During indomethacin therapy, the patency of the DA should be continuously monitored along with the umbilical artery PI. An ultrasound scan shows DA diameter at 31 weeks 6 days (3.57 mm, 6th centile). Ibuprofen was, therefore, stopped at the age of 3 months, and the parents refused to restart in fear of complication recurrence. The severity of polyhydramnios is further categorized as mild (AFI of 24.029.9 cm or DVP of 811 cm), moderate (AFI of 30.034.9 cm or DVP of 1215 cm), and severe (AFI >35 cm or DVP >16 cm) (6, 7). Ibuprofen was, therefore, stopped at the age of 3 months, and the parents refused to restart in fear of complication recurrence. Oral indomethacin has been prescribed for pregnant women for the treatment of polyhydramnios or for other indications (e.g., tocolysis in preterm labor) in doses that range between 1 and 3. OA wrote the first draft of the manuscript and contributed to the scientific literature search. doi: 10.1016/j.ajog.2007.04.019, 31. GM edited and contributed to the revision of the manuscript. FOIA Placental transfer of indomethacin in the human pregnancy, Metaanalysis of the effect of antenatal indomethacin on neonatal outcomes. Int J Gynaecol Obstet. The UK is the first country to allow OTC access to Sanofi's tadalafil-based erectile dysfunction drug Cialis following a successful switch. your institution. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Bhat YR, Vinayaka G, Vani R, Prashanth KA, Sreelakshmi K. Antenatal bartter syndrome: a rare cause of unexplained severe polyhydramnios. Amin SB, Sinkin RA, Glantz JC. sharing sensitive information, make sure youre on a federal The initial urine output was 15 ml/kg/h (normal range 12 ml/kg/h) which decreased to 7 ml/kg/h after starting ibuprofen. 2012 Mar;39(1):77-87. doi: 10.1016/j.ogc.2011.12.003. Diagnosis and management of bartter syndrome: executive summary of the consensus and recommendations from the European rare kidney disease reference network working group for tubular disorders. Differential diagnosis of bartter syndrome, Gitelman syndrome, and pseudoBartter/Gitelman syndrome based on clinical characteristics. HHS Vulnerability Disclosure, Help BS is mainly a renal tubular disorder characterized by hypochloremia and polyuria associated with a severe urinary loss of sodium chloride. Nephrocalcinosis may develop during follow-up, whereas chronic kidney disease and subsequent renal failure may complicate the condition, particularly in BS type 4 (15). Sudden fetal hematologic changes as a complication of amnioreduction in twin-twin transfusion syndrome. The effect of indomethacin tocolysis on fetal ductus arteriosus constriction with advancing gestational age. Other side effects may include nausea, vomiting, acid reflux and inflammation of the lining of the stomach (gastritis). This site needs JavaScript to work properly. Allaf B, Dreux S, Schmitz T, Czerkiewicz I, Le Vaillant C, Benachi A, et al. There were 32patients included in the study. Risk Summary: Nonsteroidal anti-inflammatory drugs (NSAIDs) use in pregnant women at 30 weeks gestation and later may cause premature closure of the fetal ductus arteriosus; NSAID use at 20 weeks gestation or later may cause fetal renal dysfunction leading to oligohydramnios and, in some cases, neonatal renal . the initial loading dose of indomethacin was generally advised between 50 and 100 mg/day and can be increased up to 23 mg/kg/day (9). Learn more about Institutional subscriptions, Indomethacin Reduces Polyhydramnios In Pregnant Women. It was challenging to determine the optimal duration and dose of indomethacin in this patient for reducing polyhydramnios without seriously affecting the patency of the DA. (2021) 99:32435. J Perinatol. Bartter's syndrome: clinical findings, genetic causes and therapeutic approach. (2007) 22:2068. The steady-state apparent clearance of indomethacin in pregnancy was shown to be higher than reported clearance data for indomethacin administered to non-pregnant subjects. doi: 10.1159/000487187, 26. - 210.65.88.143. As a library, NLM provides access to scientific literature. Diagnosis and management of bartter syndrome: executive summary of the consensus and recommendations from the European rare kidney disease reference network working group for tubular disorders, A rare cause of refractory severe polyhydramnios: antenatal bartter syndrome. doi: 10.1007/s00467-004-1527-8, Keywords: polyhydramnios, Bartter syndrome, indomethacin, Ductus Arteriosus, amniotic fluid index, Citation: Alajjuri OA, Samaha ME, Honemeyer U, Mohammed G and Mousa NA (2022) Balancing Benefits and Risks of Indomethacin in the Management of Antenatal Bartter Syndrome: A Case Report. Prenatal genomic DNA analysis from cultured amniotic cells is recognized as the most definitive diagnostic test for antenatal BS. Carlan SJ, O'Brien WF, O'Leary TD, Mastrogiannis D. Dodd JM, Crowther CA, Dare MR, Middleton P. Cochrane Database Syst Rev. Intellectual disability and sensorineural deafness can develop with some of its genetic variants (2, 22). Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Instead, the Bartter Index which is based on the multiplication of the total protein and alpha-fetoprotein (AFP) expressed as multiples of the median (MOM) was proposed as a more reliable and feasible prenatal diagnostic marker (13, 17). Common causes of polyhydramnios include gestational diabetes, fetal anomalies with disturbed fetal swallowing of amniotic fluid, fetal infections and other, rarer causes. However, there is no adequate data on its optimal dose or duration in the antenatal BS. Sharma R, Hudak M, Tepas J, Wludyka P, Teng R, Hastings L, et al. Conclusion: Results: Background: Bartter syndrome, a very rare inherited renal tubular disorder, characterized by urinary salt wastage, hypokalemia, polyuria, and metabolic alkalosis, may manifest antenatally as severe isolated polyhydramnios. All authors reviewed and agreed on the final version of this manuscript. The dose of indomethacin was accordingly reduced to 50 mg/day. The umbilical artery Doppler is a major indicator of fetal wellbeing and according to the guidelines of the Royal College of Obstetricians and Gynecologists (RCOG) on the management of small for gestational age (SGA), the delivery timing should be based on this indicator among other parameters. 8600 Rockville Pike Various treatment options have been proposed for newborns and children affected by BS, including evidence-based and controversial interventions as well-reviewed by Kleta et al. *Correspondence: Noha A. Mousa, Noha.mousa@sharjah.ac.ae, These authors have contributed equally to this work and share first authorship, Creative Commons Attribution License (CC BY). Precautions Dialysis Other Comments Usual Adult Dose for Acute Gout 50 mg orally or rectally 3 times a day Duration of therapy: Until gout attack has resolved Comments: Relief of pain has been observed within 2 to 4 hours; tenderness and heat usually subside within 24 to 36 hours; swelling gradually disappears in 3 to 5 days. In the present case study, Bartter syndrome (BS) was highly suspected based on the history of a previously affected sibling (i.e., an index case) and the exclusion of other differentials. Between December 1996 and November 1998, 46 eligible gravidas admitted with singleton pregnancies and idiopathic preterm labor before 33 gestational weeks were randomized to receive 200 mg of intravaginal or intrarectal plus oral indomethacin. UH contributed to data collection and reviewed the final version of the manuscript. In terms of the risks associated with the antenatal use of indomethacin, several have been investigated, more commonly with the use of indomethacin for its tocolytic effect in preterm labor. Bartter syndrome was suspected due to the severe isolated polyhydramnios and the normal fetal and placental structures; however, no further diagnostic steps were taken. (2010) 67:3003. Carmona F, Martnez-Romn S, Mortera C, Puerto B, Cararach V, Iglesias X. Efficacy and safety of indomethacin therapy for polyhydramnios. Amniotic fluid index, Ductus Arteriosus diameter, and umbilical artery doppler work together as key indicators to guide the success and safety of the therapy. Figure 5. Nonetheless, genomic testing currently requires specialized labs, remains slow, and is of high cost which precludes its routine application for patients with isolated polyhydramnios, as experienced with our patient. Moise Jr KJ, Ou CN, Kirshon B, Cano LE, Rognerud C, Carpenter Jr RJ. National Library of Medicine Instead, the Bartter Index which is based on the multiplication of the total protein and alpha-fetoprotein (AFP) expressed as multiples of the median (MOM) was proposed as a more reliable and feasible prenatal diagnostic marker (13, 17). Prenatal diagnosis is based upon noninvasive sonographic documentation of excessive amniotic fluid volume (AFV . The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. and transmitted securely. Intravaginal indomethacin is more effective than intrarectal plus oral application in delaying preterm labor and is associated with higher birth weights, shorter NICU stays, and shorter intervals of mechanical ventilation. However, after 16 days. Clinicians need to provide education about this condition including expectations on pregnancy management, side effects of treatment, as well as the progressive nature of polyhydramnios and the eventual premature delivery, and the long-term prognosis of affected children. Write a review. Before Since indomethacin is not recommended after 32 weeks, it was suggested to be tapered down until it is stopped (9). Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Moreover, prostaglandin E2 production is increased, which leads to electrolyte abnormalities by direct stimulation of the release of renin from the juxtaglomerular cells in the kidney (13). Cyclo-oxygenase (COX) inhibitors for treating preterm labour. It should be therefore considered, after excluding more common causes of polyhydramnios. Pregnant Woman Physical Examination Effective Treatment Caesarean Section Euro J Obst Gynecol Reprod Biol. World J Pediatr. Federal government websites often end in .gov or .mil. Rode ME, Morgan MA, Ruchelli E, Forouzan I. Candida chorioamnionitis after serial therapeutic amniocenteses: a possible association. (2021) 57:272. doi: 10.3390/medicina57030272, 24. Careers, Unable to load your collection due to an error. SMFM consult series #46: evaluation and management of polyhydramnios. (2017) 26:41925. According to recent recommendations, the mainstay of management should include high salt and water replacement, NSAIDs, potassium chloride supplements, and supportive treatment (22). Amniotic fluid index, Ductus Arteriosus diameter, and umbilical artery doppler work together as key indicators to guide the success and safety of the therapy. 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