Meconium Passage Research Articles

Meconium evacuation to improve feeding tolerance in very low birth weight preterm infants (Emita Protocol)

It has been reported that feeding tolerance in preterm infants is associated with an early passage of meconium. Prospective, randomized or historical control studies that stimulate meconium evacuation have reported varied results. This study was intented to evaluate the use of enemas to speed up meconium evacuation, facilitating feeding tolerance. A controlled multicenter randomized trial that evaluated the use of physiological saline enemas with glycerol (0.8 ml glycerol + 3 ml saline or 1 ml glycerol + 5 ml saline depending on babies weighing less or more than 800 g at birth, respectively) versus simulation. This procedure was performed in the first 96 hours of life in infants with birth weight between 500 and 1,250 g. Maternal (preterm delivery, clinical chorioamnionitis, gestational hypertension, administration of magnesium sulfate and prenatal corticosteroids, fetal Doppler altered, type of delivery, gender, weight and gestational age, assessment of Apgar and need for assisted ventilation and oxygenotherapy) and nutritional history (age when feeding volumes of 100 ml/kg/day and full enteral feeding were reached, age to remove meconium, number of days on parenteral nutrition, weight at 28 days, weekly volumes of breast milk and preterm formula) were described. No significant differences were obtained regarding the age to reach full enteral intake or 100 ml/kg/day were found among the 101 patients in the study. Also, no differences in the following secondary variables are observed: number of episodes of late sepsis with or without positive blood culture, hyperbilirubinemia, necrotizing enterocolitis and intraventricular hemorrhage. The routine use of saline enemas and glycerin in this study does not alter the enteral feeding tolerance in very low birth weight preterm infants.

The passage of meconium alone is not a sign of correctly positioned anus

Objective: The aim of this study is to determine the consequences of delayed presentation of anorectal malformations and emphasize the causes of delayed diagnosis of these malformations.Methods: We retrospectively reviewed 54 neonatal patients with a diagnosis of anorectal malformations. Group 1 consisted of 35 patients diagnosed within the first 48 h of life and Group 2 included 19 patients diagnosed after 48 h of life.Results: Obstructive symptoms at the time of diagnosis, overall complications and the mean postoperative hospitalization period in Group 2 were markedly higher than that of Group 1. A comprehensive neonatal examination within the first 48 h of life was performed in 32 (91.4%) patients in Group 1 and 5 (26.3%) of the patients in Group 2 (p < 0.001).Conclusions: The passage of meconium is not the only sign of correctly positioned anus. A careful physical examination and awareness of this anomaly are of great importance in making a timely diagnosis of anorectal malformations.

Experience with full-thickness rectal biopsy in the evaluation of patients with suspected Hirschsprung’s disease

Background and purpose Rectal biopsy is the main modality for the diagnosis of Hirschsprung’s disease (HD). In Africa, transanal full-thickness rectal biopsy is commonly performed. We aimed to audit our practice of rectal biopsy in the evaluation of HD. Materials and methods A retrospective review was carried out of the records of children (r15 years) who were evaluated for HD between 2007 and 2011. Clinical presentation, details of the operation, and histologic result were analyzed using SPSS version 15.0. Results Fifty-seven children were evaluated for suspected HD during the period. Thirty-six children underwent a rectal biopsy. There were 29 (80.6%) males and nine (19.4%) females, of which two were preterm. Neonates and infants accounted for 72.2% (n= 26). The median age at biopsy was 90 days (range, 5 days to 9 years). Delayed passage of meconium was present in 64.7%, constipation in 85.7%, abdominal distension in 88.6%, and bilious vomiting in 55.9%. Thirty biopsies (83.3%) yielded a histologic diagnosis. Twenty-six (72.2%) confirmed HD, whereas four (11.1%) yielded normal rectal histology. In six (16.7%), the sample taken was deemed inadequate for opinion. None of the symptoms assessed was associated significantly with a diagnosis of HD, stalling further analysis. Where a single biopsy was taken, 20% (n =5) were inadequate for analysis; where more than one sample was taken, a histologic diagnosis was possible in 100% (n =11). Consultant surgeons and trainees returned inadequate samples in 15.8% (n= 3) and 12.5% (n= 2), respectively. An inadequate sample was obtained in four infants (15.4%) and one child older than 1 year of age (10%). Distance of biopsy from the dentate was not indicated in 63.9% (n= 23). Conclusion No clinical parameter can accurately predict a diagnosis of HD. More than one sample at a sitting may improve the diagnostic yield. Larger prospective studies are needed to confirm these findings. Keywords : full-thickness biopsy, Hirschsprung’s disease, rectal biopsy

Development of the enteric nervous system and intestinal neuroendocrine systems in small for gestational age and average for gestational age piglets during the first month of life (1017.1)

In humans, fetal growth retardation is associated with an increased risk of intestinal problems (e.g. delayed meconium passage, abdominal distension, delay in tolerating enteral feeding, and necrotizing enterocolitis). These conditions may be related to deficits in gut development. A novel piglet model was developed to investigate the effects of birth weight and diet on the development of the enteric nervous system (ENS) and neuroendocrine system (serotonin, neurotensin, neuropeptide Y) via multivariate analyses. Newborn SGA or AGA piglets were randomized into two diet groups: sow reared (SR, 24h/day with the sow) or formula fed (FF, milk replacer) (n=4/group). Gut samples were collected at day (D) 1, 14 and 28, and used for immunohistochemistry. Along the study, innervation of the colon in SGA piglets was less developed compared to AGA piglets (p=0.007), except at D28. Serotonin and neuropeptide Y secreting cell numbers increased overtime with SR diet (p=0.0004 and p=0.004, respectively). The distribution of neurotensin cell numbers in different gut levels were highly variable overtime (p=0.0002). In conclusion, birth weight and diet influence ENS/neuroendocrine system development. This model may be useful to study intestinal maturation in low birth weight infants.

Evaluation of Safety and Efficacy of Purgative Manna (Billinaster Drop) and Glycerin Suppository in Icterus of Healthy Term Newborns

The aim of the present study was to investigate safety and efficacy of billinaster drop and glycerin suppository in hyperbilirubinemia of healthy term newborns who had passage of first meconium. In a randomized clinical trial, 90 neonates with total plasma bilirubin(TPB) level of 15-20mg/dL, were randomly assigned to be treated with alone phototherapy (control) or 5drop/kg of bilinaster drop every eight hours and phototherapy(B) or half of glycerin suppository every twelve hours and phototherapy(G). The primary outcomes were safety of drugs and efficacy in obtaining TPB of less than 14 mg/dL as measured at the beginning, 12, 24 and 48 hours after intervention. Secondary endpoint was hospitalization days. After 48 hours of intervention, achieving TPB of less than 14 mg/dL was seen in 50 %( N=15) in control group, 73.3 %( N=22) in B group and 86.7 %( N=26 neonates) in G group (P= 0.01). Watery stool was seen in two neonates of glycerin group and safety of the treatments was not significantly different. Mean of TPB 12 hours after beginning of phototherapy(mean±SD:14.38±2.27mg/dL in G, 15.97±1.96mg/dL in B and 16.67±1.77mg/dL in control), 24 hours after intervention(mean±SD:12.56 ±1.59mg/dL in G, 12.57±2.05mg/dL in B and 14.36±2.26mg/dL in control), 48 hours after intervention (mean±SD: 9.34 ± 1.6mg/dL in G, 9.96 ± 2.95mg/dL in B and 12.27 ± 2.4mg/dL in control) and mean of hospitalization days (mean± SD: 1.5 ± 0.4days in G, 1.7 ± 0.4days in B and 2.9 ± 1.1days in control) were significantly lower in glycerin and billinaster groups. Bilinaster drop and glycerin suppository can be used as hazardless, efficient and cost effective drugs in treatment of neonatal hyperbilirubinemia.

Bacteria and endotoxin in meconium-stained amniotic fluid at term: could intra-amniotic infection cause meconium passage?

Background: Meconium-stained amniotic fluid (MSAF) is a common occurrence among women in spontaneous labor at term, and has been associated with adverse outcomes in both mother and neonate. MSAF is a risk factor for microbial invasion of the amniotic cavity (MIAC) and preterm birth among women with preterm labor and intact membranes. We now report the frequency of MIAC and the presence of bacterial endotoxin in the amniotic fluid of patients with MSAF at term.Materials and methods: We conducted a cross-sectional study including women in presumed preterm labor because of uncertain dates who underwent amniocentesis, and were later determined to be at term (n = 108). Patients were allocated into two groups: (1) MSAF (n = 66) and (2) clear amniotic fluid (n = 42). The presence of bacteria was determined by microbiologic techniques, and endotoxin was detected using the Limulus amebocyte lysate (LAL) gel clot assay. Statistical analyses were performed to test for normality and bivariate comparisons.Results: Bacteria were more frequently present in patients with MSAF compared to those with clear amniotic fluid [19.6% (13/66) versus 4.7% (2/42); p < 0.05]. The microorganisms were Gram-negative rods (n = 7), Ureaplasma urealyticum (n = 4), Gram-positive rods (n = 2) and Mycoplasma hominis (n = 1). The LAL gel clot assay was positive in 46.9% (31/66) of patients with MSAF, and in 4.7% (2/42) of those with clear amniotic fluid (p < 0.001). After heat treatment, the frequency of a positive LAL gel clot assay remained higher in the MSAF group [18.1% (12/66) versus 2.3% (1/42), p < 0.05]. Median amniotic fluid IL-6 concentration (ng/mL) was higher [1.3 (0.7–1.9) versus 0.6 (0.3–1.2), p = 0.04], and median amniotic fluid glucose concentration (mg/dL) was lower [6 (0–8.9) versus 9 (7.4–12.6), p < 0.001] in the MSAF group, than in those with clear amniotic fluid.Conclusion: MSAF at term was associated with an increased incidence of MIAC. The index of suspicion for an infection-related process in postpartum women and their neonates should be increased in the presence of MSAF.

Intrahepatic Cholestasis of Pregnancy and Associated Adverse Pregnancy and Fetal Outcomes

Intrahepatic cholestasis of pregnancy (ICP) is a common liver disease, with incidence rates of 0.4% to 15%. Intrahepatic cholestasis of pregnancy is characterized by unexplained pruritus, classically of the palms and soles, with elevated bile acids or transaminases in the late second or third trimester of pregnancy. Adverse fetal outcomes include spontaneous preterm birth, antenatal passage of meconium, and stillbirth. In a nationwide cohort of singleton births in Sweden, between 1997 and 2009, the prevalence of ICP and association with adverse pregnancy and fetal outcomes were assessed. The Swedish Medical Birth Register listed 1,213,668 singleton deliveries occurring in 1997 to 2009. Covariate data were maternal age at delivery, patient’s antenatal body mass index, parity, cigarette smoking, coexisting diseases, preeclampsia, and gestational diabetes. Infant data included small for gestational age, large for gestational age (LGA), macrosomia, postterm pregnancy, moderate and very preterm birth, stillbirth, low Apgar score, and neonatal death. The main outcome measure was stillbirth. Secondary outcomes were gestational diabetes, preeclampsia, preterm birth, neonatal death, low Apgar score, meconium aspiration, LGA, macrosomia, small for gestational age, and mode of labor onset. The risk of adverse pregnancy outcomes was determined in relation to ICP by crude odds ratios (ORs) and adjusted ORs (aORs) with 95% confidence intervals (CIs). Data were analyzed using SAS 9.2. A total of 5477 singleton births were to mothers with ICP. Essential hypertension was present in 1.1% and 0.6% of women with and without ICP, respectively; rates for diabetes mellitus were 1.3% and 0.4%, respectively. Women with ICP had an increased risk of gestational diabetes (aOR, 2.81; 95% CI, 2.32–3.41) and preeclampsia (aOR, 2.62; 95% CI, 2.32–2.78) compared with women without ICP. No increased risks of antepartum bleeding or placental complications (aOR, 0.78; 95% CI, 0.56–1.07) were found. A strong association was apparent between ICP and moderate preterm birth (aOR, 3.30; 95% CI, 3.00–3.63); the risk of very preterm birth was decreased (aOR, 0.47; 95% CI, 0.27–0.81). Women with ICP had a higher risk of undergoing cesarean section (CS; aOR 1.26; 95% CI, 1.13–1.33), specifically emergency CS; no associated risk was seen for elective CS (aOR, 1.04; 95% CI, 0.93–1.16). A strong association was noted between ICP and labor induction (aOR, 11.76; 95% CI, 11.04–12.52). When analysis was restricted to women with spontaneous labor onset, the aOR for emergency CS among women with ICP was 1.25 (95% CI, 1.05–1.50). The highest risk for preterm birth in women with ICP was for iatrogenic preterm birth (aOR, 5.95; 95% CI, 5.23–6.60); the risk for spontaneous preterm birth was only marginally increased (aOR, 1.60; 95% CI, 1.47–1.93). Women with ICP had a significantly reduced risk for postterm delivery (aOR, 0.21; 95% CI, 0.17–0.21). No significant increases were noted in risk of neonatal death (aOR, 0.45; 95% CI, 0.15–1.40) or meconium aspiration (aOR, 1.41; 95% CI, 0.72–2.72). Infants of women with ICP were significantly more likely to have an Apgar score of less than 7 at 5 minutes (aOR, 1.45; 95% CI, 1.14–1.85) and were more often LGA (aOR, 2.27; 95% CI, 2.02–2.55). For deliveries with spontaneous labor, the aOR for Apgar score of less than 7 at 5 minutes for women with ICP was 1.78 (95% CI, 1.19–2.64). Women with ICP who were actively managed were not at an increased risk for stillbirth compared with women without ICP. The association of ICP with gestational diabetes and preeclampsia is important to consider in the diagnostic process for women with ICP to improve clinical management. Further studies of ICP-related morbidity should focus on the shared pathologic mechanisms leading to preeclampsia and gestational diabetes.

Index of Suspicion in the Nursery

A 3.7-kg, 6-day-old term infant presents to the emergency department with decreased oral intake, irritability, and respiratory distress. No history of fever, or respiratory or gastrointestinal symptoms are elicited. Prenatal and delivery history are unremarkable, including negative maternal serologies and Group B streptococcus testing. Mother is healthy, but the sibling has rhinorrhea and cough. The infant is intubated for respiratory distress, receives 60 mL/kg of normal saline boluses for poor perfusion, and dopamine is started for hypotension. The infant is noted to have a blanching, maculopapular erythematous rash involving the axilla and trunk, but otherwise has a nonfocal physical examination. A sepsis evaluation is performed, including blood, urine, and cerebrospinal fluid (CSF) cultures. Empirical antimicrobial therapy with ampicillin, gentamicin, and acyclovir is administered, and the infant is transferred to the NICU for further management. A 6-week-old healthy boy presents with bilateral painless scrotal swelling. He was born at term via normal vaginal delivery following an uneventful pregnancy; antenatal ultrasound scans were normal. The scrotal mass had been present since birth and initially was believed to be a hydrocele but it had become firmer over a course of 6 weeks. On physical examination, it consisted of two small, grape-size swellings, one above the left testis and one below the right testis. There was no history of delayed passage of meconium or any sign of bowel obstruction. Plain abdominal radiograph was performed and did not show intra-abdominal calcifications. An ultrasound scan demonstrated that both testes were normal in size, shape, and echodensity. Within the right and left scrotum there were paratesticular masses of mixed echogenicity. Both masses could be traced toward the inguinal canal, as shown in Fig 1. There were no abdominal calcifications. Sweat test and tissue culture were performed to exclude cystic fibrosis and tuberculosis, respectively, and were negative. …

Colestasis del embarazo

La colestasis intrahepática del embarazo (CIDE) se caracteriza por prurito en la segunda mitad del embarazo, prurito que no se asocia con otros problemas dermatológicos o sistémicos. El diagnóstico se confirma con la elevación de los niveles maternos de bilirrubina, enzimas hepáticas y ácidos biliares en ayunas. El pronóstico para el feto es serio, pues la CIDE está asociada con pasaje de meconio, partos prematuros y muerte fetal. El tratamiento con tabletas de ácido ursodeoxicólico (UDCA) mejora el prurito, las pruebas de laboratorio y disminuye los resultados fetales adversos. Para la embarazada, la CIDE es relativamente benigna; pero, se ha observado que en el futuro estas mujeres tienen un riesgo mayor de presentar problemas hepatobiliares, cáncer de la mama e hipotiroidismo que las mujeres que no tuvieron esta complicación. Se recomienda un seguimiento prolongado. Palabras clave: Ultrasonido, HDLive US, Obstetricia, Ginecología.

Functional constipation in children: the pediatric surgeon’s perspective

The prevalence of functional constipation in children is almost 10%. The etiology is multifactorial and not fully understood. In the majority of cases, there is no organic explanation for the symptoms. However, it is very important to exclude organic causes, particularly in neonates and infants. There are warning symptoms, such as delayed passage of meconium, bilious vomiting and abdominal distention that should prompt further investigations. Fecal incontinence is a very common symptom secondary to fecal impaction. The first-line treatment for both disimpaction and maintenance is use of laxatives. Parental education is extremely important. There are very limited data on surgical approaches for functional constipation.

Index of Suspicion

* ALT: : alanine aminotransferase AST: : aspartate aminotransferase BUN: : blood urea nitrogen CBC: : complete blood count CNS: : central nervous system CSF: : cerebrospinal fluid CT: : computed tomography ECG: : electrocardiography ED: : emergency department EEG: : electroencephalography ESR: : erythrocyte sedimentation rate GI: : gastrointestinal GU: : genitourinary Hct: : hematocrit Hgb: : hemoglobin MRI: : magnetic resonance imaging WBC: : white blood cell An 11-year-old boy presents to the emergency department with a 1-week history of frequent episodes of nonbloody, nonbilious emesis associated with diarrhea and abdominal cramping. He has urgency and fecal incontinence. He has been afebrile and denies any rashes, joint pain, sick contacts, headaches, or other symptoms. On further questioning, his mother reveals that he has had 2 similar episodes of abdominal distension and diarrhea during the past 6 to 7 years. Between these episodes, she states that he normally has nonbloody, hard stools accompanied by straining and chronic abdominal pain and pain with defecation. When asked specifically, his mother does not remember when he passed his first stool after he was born. On physical examination, his temperature is 37.6°C, pulse is 100 beats per minute, respiratory rate is 16 breaths per minute, blood pressure is 113/62 mm Hg, oxygen saturation is 100% on room air, height is 63 inches (95%), and weight is 36.7 kg (25%). He has abdominal distention and diffuse abdominal tenderness with voluntary guarding. There is palpable stool in the left quadrant. There is no perianal erythema or skin tag, and rectal examination reveals a low anal tone. A CT scan of the abdomen (Figure 1) reveals a markedly distended rectosigmoid colon with circumferential, confluent, and contiguous mural thickening. Basic metabolic profile, CBC, and urinalysis results are unremarkable, but the C-reactive protein level is elevated at 131 mg/L (1248 nmol/L). Because of the concern for enterocolitis, he is empirically given broad-spectrum intravenous antibiotics and transferred to a children’s hospital for further evaluation. Figure 1. A CT scan of the abdomen shows a markedly distended rectosigmoid colon with circumferential mural thickening. A 4-year-old boy presents for evaluation of intermittent fevers of 4 weeks’ duration after 2 separate antibiotic courses prescribed for acute otitis media. He has experienced clear rhinorrhea and …

Comparative Evaluation of 25µg and 50µg of travaginal Misoprostol for Induction of Labor

&#x0D; Introduction: To compare the efficacy and safety of 25g vs. 50g of intravaginal (Posterior fornix) misoprostol for induction of labor in 100 patient from Jan 2012 to Dec 2012 at Lumbini Medical College.&#x0D; &#x0D; Methods: One hundred pregnant lady requiring induction were randomly assigned to receive either 25 g (group A=50) or 50 g (group B=50) of intra vaginal misoprostol every 4 hrs till adequate contractions were achieved or maximum dose of 150 g was used.&#x0D; &#x0D; Results: The onset of contraction was earlier in group B in 34 cases as compared to group A, where only 25 cases had earlier contraction ( P&gt; 0.05). 38 cases (76%) in Group B and 35 cases (70%) in Group A delivered vaginally. Induction to delivery interval was shorter(&lt;12hrs) in group B in 15 cases and in 10 cases in group A. Mean dose of Misoprostol (94micrograms) for successful induction in group B was high compared to Group A (75.5 microgram). Requirement for oxytocin infusion was higher in group A, 26% vs. 15%. Abnormal contractility pattern was seen in B group 24% cases compared to 14% cases in Group A. APGAR score &lt; 7 at 1 min was seen in 26% neonates in Group B and in only 10% neonates in Group A. Ruptured uterus did not occur in any group.&#x0D; &#x0D; Conclusion: 50 g dose of misoprostol is more efficacious than 25 g dose as seen in our study. However it appears to be less safe both for mother and baby due to the high incidence of tachysystole, hyperstimulation and intrauterine passage of meconium.

Interventions for treating cholestasis in pregnancy.

Obstetric cholestasis has been linked to adverse maternal and fetal/neonatal outcomes. As the pathophysiology is poorly understood, therapies have been empiric. The first version of this review, published in 2001, and including nine randomised controlled trials involving 227 women, concluded that there was insufficient evidence to recommend any of the interventions alone or in combination. This is the first update. To evaluate the effectiveness and safety of therapeutic and delivery interventions in women with cholestasis of pregnancy. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 February 2013) and reference lists of identified studies. Randomised controlled trials that compared two intervention strategies for women with a clinical diagnosis of obstetric cholestasis. The review authors independently assessed trials for eligibility and risk of bias. We independently extracted data and checked these for accuracy. We included 21 trials with a total of 1197 women. They were mostly at moderate to high risk of bias. They assessed 11 different interventions resulting in 15 different comparisons.Compared with placebo, ursodeoxycholic acid (UDCA) showed improvement in pruritus in five (228 women) out of seven trials. There were no significant differences in instances of fetal distress in the UDCA groups compared with placebo (average risk ratio (RR) 0.67; 95% confidence interval (CI) 0.22 to 2.02; five trials, 304 women; random-effects analysis: T² = 0.74; I² = 48%). There were significantly fewer total preterm births with UDCA (RR 0.46; 95% CI 0.28 to 0.73; two trials, 179 women). The difference for spontaneous preterm births was not significant (RR 0.99; 95% CI 0.41 to 2.36, two trials, 109 women).Two trials (48 women) reported lower (better) pruritus scores for S-adenosylmethionine (SAMe) compared with placebo, while two other trials of 34 women reported no significant differences between groups.UDCA was more effective in improving pruritus than either SAMe (four trials; 133 women) or cholestyramine (one trial; 84 women), as was combined UDCA+SAMe when compared with placebo (one trial; 16 women) and SAMe alone (two trials; 68 women). However, combined UDCA+SAMe was no more effective than UDCA alone in regard to pruritus improvement (one trial; 53 women) and two trials (80 women) reported data were insufficient to draw any conclusions from. In one trial comparing UDCA and dexamethasone (83 women), a significant improvement with UDCA was seen only in a subgroup of women with severe obstetric cholestasis (23 women).Danxiaoling significantly improved pruritus in comparison to Yiganling. No significant differences were seen in pruritus improvement with other interventions.Eight trials reported fetal or neonatal deaths, with two deaths reported overall (both in the placebo groups).Women receiving UDCA and cholestyramine experienced nausea, vomiting and diarrhoea. Guar gum caused mild abdominal distress, diarrhoea and flatulence during the first days of treatment. Women found charcoal suspension unpleasant to swallow. Dexamethasone caused nausea, dizziness and stomach pain in one woman.One trial (62 women) looked at the timing of delivery intervention. There were no stillbirths or neonatal deaths in 'early delivery' or the 'await spontaneous labour' group. There were no significant differences in the rates of caesarean section, meconium passage or admission to neonatal intensive care unit between the two groups. Different approaches to assessing and reporting pruritus precluded pooling of trials comparing the effects of UDCA versus placebo on pruritus, but examination of individual trials suggests that UDCA significantly improves pruritus, albeit by a small amount. Fewer instances of fetal distress/asphyxial events were seen in the UDCA groups when compared with placebo but the difference was not statistically significant. Large trials of UDCA to determine fetal benefits or risks are needed.A single trial was too small to rule in or out a clinically important effect of early term delivery on caesarean section.There is insufficient evidence to indicate that SAMe, guar gum, activated charcoal, dexamethasone, cholestyramine, Salvia, Yinchenghao decoction (YCHD), Danxioling and Yiganling, or Yiganling alone or in combination are effective in treating women with cholestasis of pregnancy.

The football sign in a neonate

A male neonate was born at term following an uneventful delivery. At 12 h old, breast feeding was readily accepted after passing the initial day 1 postnatal check. By 36 h, there was still no meconium passage and he developed progressive abdominal distension and large volume bilious vomiting. Subsequently, fever and tachypnea developed and he was admitted to our hospital. On examination, there was marked abdominal distension (Figure 1 …

Efficacy and Safety of Continuous Infusion of Fentanyl for Pain Control in Preterm Newborns on Mechanical Ventilation

To evaluate the analgesic superiority and the safety equivalence of continuous fentanyl infusions versus fentanyl boluses in preterm infants on mechanical ventilation. In this multicenter, double-blind, randomized controlled trial, mechanically ventilated newborns (≤ 32(+6) weeks gestational age) were randomized to fentanyl (continuous infusion of fentanyl plus open-label boluses of fentanyl) or placebo (continuous infusion of placebo plus open-label boluses of fentanyl). The primary endpoint was analgesic efficacy, as evaluated by the Echelle Douleur Inconfort Nouveau-Né (EDIN) and Premature Infant Pain Profile scales. Safety variables were evaluated as well. Sixty-four infants were allocated to the fentanyl group, and 67 were allocated to the placebo group. The need for open-label boluses of fentanyl was similar in the 2 groups (P = .949). EDIN scores were comparable in the 2 groups; 65 of 961 (6.8%) EDIN scores were >6 in the fentanyl group and 91 of 857 (10.6%) in the placebo group (P = .003). The median Premature Infant Pain Profile score was clinically and statistically higher in the placebo group compared with the fentanyl group on days 1, 2, and 3 of treatment (P < .05). Mechanical ventilation at age 1 week was required in 27 of 64 infants in the fentanyl group (42.2%), compared with 17 of 67 infants in the placebo group (25.4%) (P = .042). The first cycle of mechanical ventilation was longer and the first meconium passage occurred later in the fentanyl group (P = .019 and .027, respectively). In very preterm infants on mechanical ventilation, continuous fentanyl infusion plus open-label boluses of fentanyl does not reduce prolonged pain, but does reduce acute pain and increase side effects compared with open-label boluses of fentanyl alone.

A new diagnostic scoring system to differentiate Hirschsprung’s disease from Hirschsprung’s disease-allied disorders in patients with suspected intestinal dysganglionosis

To create a simple diagnostic scoring system to differentiate Hirschsprung's disease (HD) from Hirschsprung's disease-allied disorders (HAD) in patients with suspected intestinal dysganglionosis (IDs). Between 1998 and 2008, 967 patients with suspected intestinal dysganglionosis underwent surgical treatment at the pediatric surgery department of Tongji Hospital. The diagnosis of HD or HAD was confirmed by postoperative pathological examination. All patients underwent preoperative work-up including barium enema, anorectal manometry, and histochemical acetylcholinesterase staining of rectal mucosa. Known risk factors for IDs were recorded. The predicting score was calculated by summing the scores of the risk factors and three preoperative tests. The sensitivity, specificity, accuracy, positive predictive values, negative predictive values, positive likelihood ratios, and negative likelihood ratios of the predicting score were calculated. The cutoff score for predicting HD was determined using receiver operating characteristic (ROC) analysis. The accuracy of the predicting score was measured by the area under the ROC curve. Failed or delayed passage of meconium, age <3 years and male gender were risk factors associated with HD. The area under the ROC curve of the predicting score was 0.927 (95 % confidence interval, 0.910-0.944). A predicting score of more than 5 was used as a cutoff for predicting HD. The scoring system achieved 83.1 % sensitivity, 89.5 % specificity, and 85.9 % accuracy in predicting HD. Patients with a predicting score of more than 5 are more likely to be diagnosed with HD, whereas a score less than 5 are mostly indicative of HAD.

Obstetric cholestasis: Outcome with active management

To study the nature and clinical outcome of pregnancies with obstetric cholestasis on active management and to correlate perinatal outcome to gestational age at delivery. This prospective randomized study included 69 women with obstetric cholestasis. Fetal surveillance began at 34 weeks or later at diagnosis and included daily maternal record of fetal movements, and biophysical profile (i.e. non stress test, the four quadrant amniotic fluid index). Fetal monitoring was conducted weekly before 36 weeks and biweekly after that. Randomization into two groups was done where one group was planned for delivery at 37 weeks whereas in the other group, pregnancy was carried to 38 weeks under surveillance. The primary outcome variable was correlation of fetal and neonatal complication rates to gestational age at delivery. There were no stillbirths in the study. No episode of fetal asphyxia or bradycardia was observed. The overall rate of meconium passage was 7.46% (5/67). However, there was no case of meconium aspiration syndrome. Women delivering at or after 38 weeks had a lower incidence of cesarean section (17.85% vs 25.8%), neonatal nursery admission (17.85% vs 22.5%), and neonatal jaundice (17.85% vs 19.35%) compared to those delivering at 37 weeks. The differences between the two groups were, however, not found to be statistically significant. The current study demonstrates that with active intervention, pregnancies with obstetric cholestasis can be carried to a later gestation under surveillance.

Duration of Meconium Passage in Term and Preterm Infants

Delayed first passage of meconium and also prolongation of meconium passage creates great anxiety among parents. Some study showed that that first passage of meconium is delayed in preterm infants compared to term infants. The difference in duration of meconium passage in term and preterm infant has however never been assessed before. This cross sectional study was carried between July 2010 to December 2010 among 100 Newborn babies ranging from 28 to 42 weeks of gestation who were delivered in the Department of Obstetrics and Gynaecology or admitted in the Department of Neonatology of Dhaka Medical college Hospital were included in the study. Gestational age was determined from first day of last menstruation (when available) and also by using Expanded Ballard Scoring System. In case of any discrepancy of more than 2 weeks, the later was accepted. This study was carrying out to determine the time of first passage of meconium and duration of passage of meconium in term and preterm infants. Out of total 100 infants, 58 were male and 42 were female. The numbers of babies were 21, 28, 25 and 26 in group I, II, III and IV respectively. The mean age at which the babies passed first meconium were 23.5±3.5, 33.0±3.8, 25.7±4.2 and 17.3±4.6 hours in group I, II, III and IV respectively, which was&lt;48 hours irrespective of gestational age. The mean gestational age of the babies who passed meconium for &lt;4 days was 37.1±2.2 weeks. On the contrary, mean gestational age of the babies who passed meconium for&gt;4 days was 32.6±4.3 weeks and this observation was statistically significant (p&lt;0.001). First passage of meconium in all newborn was within 48 hours irrespective of gestational age. Duration of passage of meconium was significantly prolonged among babies with lower gestational age. DOI: http://dx.doi.org/10.3329/akmmcj.v4i1.13677 AKMMC J 2013; 4(1): 6-9

English

OBJECTIVES : To evaluate efficacy of sublingual misoprostol versus oxytocin drip for induction and augmentation of labor in prelabor rupture of membranes. METHODS : The study included 200 pregnant women with singleton term pregnancy with cephalic presentation, leaking per vaginum and no contraindications to vaginal delivery. They were randomised in two groups, 100 in sublingual misoprostol group and 100 for oxytocin drip group. Induction delivery interval, mode of delivery, incidence of operative interference and maternal and fetal outcome were noted and analysed. RESULTS : Mean induction delivery interval was 8 hrs in misoprostol group and 15 hrs in oxytocin group. Mode of delivery was vaginal in 99% in misoprostol group but 80% in oxytocin group. Sublingual misoprostol was associated with less meconium passage (1%) compared to 20% in oxytocin group. CONCLUSION : Sublingual misoprostol is a good alternative to oxytocin drip for induction and augmentation of labour in women with PROM.

Time of passage of first stool in newborns in a tertiary health facility in Southern Nigeria

Introduction:The first stool passed by the newborn, the meconium, is different from the ordinary stool both in its nature and its implication. Delayed or non-passage of the meconium may represent a number of clinical conditions. In this study, we sought to identify what should be considered delayed passage of meconium in our babies.Aims and Objectives:To investigate the timing of passage of first stool in Nigerian neonates and whether it is influenced by gender, birth weight, maternal age, and parity.Materials and Methods:A proforma was designed to obtain the following data: Maternal age, parity, mode of delivery, Apgar score at 1 min, birth weight, gender, and interval between delivery and passage of first stool among normal newborn babies delivered at the obstetrics department of our center in August and September 2010.Results:One hundred babies out of 393 delivered during the period of the study were included in the study. There were 63 (63%) males and 37 (37%) females. The interval between delivery and passage of meconium ranged from 0.5 to 54 h; mean, 16.2 (SD = 10.57). This was not influenced by gender, weight, maternal age, and parity.Conclusion:Non-passage of meconium beyond 48 h of life could be considered delayed. We therefore, recommend that clinicians should re-evaluate newborns, for hitherto unrecognized conditions, if after 48 h they have not passed first stool.