To the editor:
In their POEM review of the article “Risk of adverse birth outcome and miscarriage in pregnant users of non-steroidal anti-inflammatory drugs,” Srinivasan and Rao1 seem to give pregnant women a blanket reassurance that except for the association with miscarriage, nonsteroidal anti-inflammatory drug (NSAID) use is safe. However, since NSAIDs can alter renal cortical circulation in adults, they can decrease fetal urine output leading to oligohydramnios. COX-2 inhibitors have been associated with fetal renal failure.2 Indomethacin, when used as a tocolytic, has been also associated with closure of the ductus,3 increased risk of interventricular hemorrhage,4 and necrotizing enterocolitis.5 Although occasional use of an NSAID may be safe in pregnancy, in general, they should be avoided especially in fetuses with oligohydramnios, ductus dependent cardiac anomalies, and thrombocytopenia.
Neal Devitt, MD
References
- Srinivasan S, Rao G. J Fam Pract 2001; 50:467.
- Peruzzi L, Gianoglio B, Porcellini MG, Coppo R. Lancet 1999; 354:1615.
- Moise KJ. Am J Ob Gyn 1993; 168:1350-53.
- Norton ME, Merrill J, Cooper BAB, et al. N Engl J Med 1993; 329:1602-07.
- Major CA, Lewis DF, Harding JA, et al. Am J Ob Gyn 1994; 170:102-06.
Drs Srinivasan and Rao responded as follows:
We appreciate the input of Dr Devitt on this matter. However, as noted in the study design section of the POEM, the researchers only tracked usage of ibuprofen (400 mg or 600 mg) prescriptions for the study. Therefore, conclusions cannot be drawn about other NSAIDs, such as indomethacin. Also, the only outcomes reported in the study were congenital abnormality, low birth weight, preterm birth, and miscarriage. Data about other complications for the fetus such as renal failure were not reported. Therefore, as Dr Devitt suggests, clinicians can only offer advice to patients about ibuprofen’s safety with regard to these outcomes, strictly based on the data from this study. We hope these clarifications help readers draw appropriate conclusions from the POEM.
Sukanya Srinivasan, MD
Goutham Rao, MD
UPMC St. Margaret Family Practice Residency Pittsburgh,
Pennsylvania