Hydrops Fetalis Caused by Maternal Indomethacin Treatment

The etiology of nonimmunological hydrops fetalis is unclear. Most often, severe anemia or heart failure are common features in the pathogenesis of the disease. Congestive heart failure during intrauterine life, which is a common pathological mechanism for edema formation, has been seen with premature closure of the ductus arteriosus. Intrauterine cardiac failure due to premature closure of the ductus has been reported in a newborn after salicylate administration to the mother. Other prostaglandin inhibitors (e.g., indomethacin), which also cause closure of the ductus, have been used lately to prevent premature delivery. The purpose of this report is to emphasize previous words of caution about the use of indomethacin to halt premature labor. Hydrops fetalis in one twin, in the absence of vascular placental connection between fetal circulations or any other sign of fetus-to-fetus transfusion, is described.A 23-year-old gravida 2, para 0, was admitted with early onset of labor at 33 weeks of gestation. Ultrasound examination disclosed a twin pregnancy. Premature contractions were confirmed by external monitoring. Intravenous administration of Ritodrine was started, but indomethacin became necessary because of inadequate response to Ritodrine. A course of 100 mg of indomethacin per day was interrupted after 9 days because of rupture of the membranes and onset of contractions. Identical male twins were delivered by vacuum extraction and partial breech extraction, respectively. Careful examination of the monochorionic placenta failed to reveal any connection between the fetal circulations or any other anomaly. This excludes twin-to-twin vascular connection as a cause of hydrops fetalis.Twin A weighed 2040 g, had an Apgar score of 2 at one minute, and required assisted ventilation. The gestation age was 37 weeks. Clinical signs of pallor, poor perfusion, and a systolic blood pressure of 20 mm Hg were consistent with shock. His general condition improved after 10 cc/kg of 5 per cent intravenously administered human albumin. An enlarged heart shadow appeared on an AP chest x-ray. Sixty per cent oxygen was required for a few hours. The enlarged heart returned to normal size by the 2nd day.Twin Bʼs birth weight was 2570 g. The Apgar score was 2 after the first minute and 6 after five minutes. Following delivery, respiratory effort was absent. The baby was pale, and his face, neck, penis, scrotum, and extremities appeared very edematous. The abdomen was distended by