Retrospective review of antimicrobial use for gastroschisis patients in Kigali, Rwanda: can improved stewardship reduce late inpatient deaths?

Gastroschisis mortality is 75-100% in low-resource settings. In Rwanda, late deaths are often due to sepsis. We aimed to understand the effect of antimicrobial use on survival. We conducted a retrospective review of gastroschisis patients at a tertiary hospital in Kigali, Rwanda between January 2016-June 2019. Demographics, antimicrobial use, microbiology, and outcomes were abstracted. Descriptive and univariate analyses were conducted to assess factors associated with improved survival. Among 92 gastroschisis patients, mortality was 77%(n = 71); 23%(n = 21) died within 48 h. 98%(n = 90) of patients received antibiotics on arrival. Positive blood cultures were obtained in 41%(n = 38). Patients spent 86%(SD = 20%) of their hospital stay on antibiotics and 38%(n = 35) received second-line agents. There was no difference in age at arrival, birth weight, gestational age, silo complications, or antimicrobial selection between survivors and non-survivors. Late death patients spent more total hospital days and post-abdominal closure days on antibiotics (p < 0.001) compared to survivors. There was no difference in the proportion of hospital stay on second-line antibiotics (p = 0.1). CONCLUSION: We identified frequent late deaths, prolonged antibiotic courses, and regular use of second-line antibiotic agents in this retrospective cohort of Rwandan gastroschisis patients. Future studies are needed to evaluate antimicrobial resistance in pediatric surgical patients in Rwanda. WHAT IS KNOWN: • Global disparities in gastroschisis outcomes are extreme, with <4% mortality in high-income settings and 75-100% mortality in low-income settings. • Antimicrobial surveillance data is sparse across Africa, but existing evidence suggests high levels of resistance to first-line antibiotics in Rwanda. WHAT IS NEW: • In-hospital survival for gastroschisis was 23% from 2016-2019 and most deaths occurred late (>48hrs after admission) due to sepsis. • Rwandan gastroschisis patients received prolonged courses of antibiotics and second-line antibiotics were frequently used without culture data, raising concern for antimicrobial resistance.

Eventos adversos associados às doses de fentanil utilizadas nos primeiros dez de vida em neonatos submetidos à correção de gastrosquise / Adverse events associated with doses of fentanyl used in the first ten days of life in neonates undergoing gastroschisis repair

Objetivo: Avaliar a associação entre as doses de fentanil utilizadas nos primeiros dez dias de vida de neonatos submetidos à correção cirúrgica de gastrosquise e as complicações respiratórias e gastrointestinais comumente associadas à essa faixa etária e defeito congênito. Métodos: O presente estudo avaliou de forma retrospectiva a coorte de recém-nascidos portadores de gastrosquise operados no IFF no período de janeiro de 2016 até junho de 2021. Dados demográficos dos neonatos e gestantes, das intervenções cirúrgicas, dos procedimentos anestésicos e dos cuidados perioperatórios em unidade de terapia intensiva neonatal foram coletados de prontuários. Os principais desfechos avaliados foram o tempo de intubação orotraqueal e de ventilação mecânica (IOT/VM), tempo de uso de NPT e data de início de dieta enteral. Foram descritos, tempo para dieta oral plena, tempo de internação em unidade de cuidados intensivos neonatais, diagnóstico de sepse, diagnóstico de apnéia, estridor, pneumonia e taxa de mortalidade. Nos primeiros dez dias de vida dos bebês, as doses de fentanil utilizadas no intraoperatório e periopratório, em bolus ou infusão contínua, foram quantificadas. Assim como, fez-se uma análise descritiva das abordagens cirúrgicas, das técnicas anestésicas e das complicações clínico-cirúrgicas apresentadas durante o período de internação na UTI. Por meio de modelagem estatística, o impacto do aumento das dose de fentanil sobre as complicações respiratórias e gastrointestinais foi avaliado. Resultados: No período do estudo 184 crianças receberam correção cirúrgica do defeito de parede no IFF e a taxa de mortalidade foi de 8,69%. Os dados de 176 neonatos foram coletados e 94% desses pacientes foram indentificadas como gastrosquise simples. Nossa coorte de 144 pacientes foi avaliada e os eventos mais frequentemente relacionados ao uso de maiores doses de fentanil foram aumento do tempo de ventilação mecânica, aumento do tempo total de uso de NPT e retardo para início da dieta enteral. Conclusão: O estudo mostrou piores desfechos respiratórios e gastrointestinais nos pacientes que receberam doses maiores de fentanil.

Objective: To evaluate the association between doses of fentanyl used in the first ten days of life in neonates undergoing surgical correction of gastroschisis and the respiratory and gastrointestinal complications commonly associated with this age group and congenital defect. Methods: This study evaluated retrospectively the cohort of newborns with gastroschisis operated at IFF between January 2016 and June 2021. Demographic data of newborns and pregnant women, surgical interventions, anesthetic procedures and perioperative care in the neonatal intensive care unit were collected from medical records. The main outcomes evaluated were time of orotracheal intubation and time on mechanical ventilation (TI/MV), time of use of PN, time to start enteral nutrition, time to full oral diet, length of stay in the neonatal intensive care unit, sepsis diagnosis, diagnosis of apnea,stridor, pneumonia and mortality rate. In the first ten days of the babies' lives, the doses of fentanyl used in the intraoperative and perioperative, in bolus or continuous infusion, were quantified. As well, a descriptive analysis of surgical approaches, anesthetic techniques and the clinical-surgical complications presented during the ICU stay was made. Through statistical modeling, the impact of increasing fentanyl doses on respiratory and gastrointestinal complications was evaluated. Results: During the study period, 184 children received surgical correction of the wall defect at IFF and the mortality rate was 8.69%. The data from 176 neonates were collected and 94% of these patients were identified as simple gastroschisis. Our cohort of 144 patients was evaluated and the most frequently related events to the use of fentanyl in higher doses were increased time on mechanical ventilation, increased total time of PN use, and delay in starting enteral feeding. Conclusion: The study demontrated worse respiratory and gastrointestinal outcomes in the neonates that received higher doses of fentanyl.

Antenatal corticosteroids and outcomes in gastroschisis: A multicenter retrospective cohort study.

OBJECTIVE: In gastroschisis, there is evidence to suggest that gut dysfunction develops secondary to bowel inflammation; we aimed to evaluate the effect of maternal antenatal corticosteroids administered for obstetric reasons on time to full enteral feeds in a multicenter cohort study of gastroschisis infants. METHODS: A three center, retrospective cohort study (1992-2013) with linked fetal/neonatal gastroschisis data was conducted. The primary outcome measure was time to full enteral feeds (a surrogate measure for bowel function) and secondary outcome measure was length of hospital stay. Analysis included Mann-Whitney and Cox regression. RESULTS: Of 500 patients included in the study, 69 (GA at birth 34 [25-38] weeks) received antenatal corticosteroids and 431 (GA at birth 37 [31-41] weeks) did not. Antenatal corticosteroids had no effect on the rate of reaching full feeds (Hazard ratio HR 1.0 [95% CI: 0.8-1.4]). However, complex gastroschisis (HR 0.3 [95% CI: 0.2-0.4]) was associated with an increased time to reach full feeds and later GA at birth (HR 1.1 per week increase in GA [95% CI: 1.1-1.2]) was associated with a decreased time to reach full feeds. CONCLUSION: Maternal antenatal corticosteroids use, under current antenatal steroid protocols, in gastroschisis is not associated with an improvement in neonatal outcomes such as time to full enteral feeds or length of hospital stay.

Enhanced Vancomycin Elimination in an Infant Following an Unsuccessful Gastroschisis Repair Surgery.

OBJECTIVE: To report the case of an infant who required high-dose vancomycin therapy after an unsuccessful gastroschisis repair surgery. CASE SUMMARY: An infant born at 35 weeks and 5 days of gestation underwent a gastroschisis repair on day of life 47. The repair was unsuccessful causing fluid backup and accumulation into the stomach. A replogle was placed to allow for suctioning of this fluid. During this admission, the patient received 3 courses of vancomycin. During the first course, the patient had minimal output via the replogle tube. On the infant's second and third courses of vancomycin, the infant necessitated vancomycin dosing above that of the neonatal protocol, and subsequent levels were still found to be below goal. Vancomycin was increased to a maximum of 15 mg/kg every 4 hours (90 mg/kg/d) in order to achieve serum trough levels greater than 10 mg/L. Residuals were drawn from the replogle ranging from 0.76 to 4.33 mL/kg/h during the second and third course of vancomycin. DISCUSSION: A premature male infant required up to 90 mg/kg/d of vancomycin to achieve trough levels above 10 mg/L after an unsuccessful gastroschisis repair surgery and gastric suctioning. CONCLUSION: Clinicians should be aware of the possibility for decreased vancomycin levels and the potential need for increased monitoring in postsurgical infants receiving gastric suctioning.

Evaluation of Early Onset Sepsis, Complete Blood Count, and Antibiotic Use in Gastroschisis.

OBJECTIVE: Gastroschisis is a congenital defect in which the abdominal viscera herniate through the abdominal wall. In this population, antibiotics are often initiated immediately following delivery; however, this may be unnecessary as infections typically develop as a consequence of chronic issues in gastroschisis. The objective of this study was to evaluate the incidence of culture positive early onset sepsis, the reliability of the immature to mature neutrophil count (I:T) ratio as an infectious biomarker, and antibiotic use in infants with gastroschisis. STUDY DESIGN: This retrospective chart review analyzed clinical data from 103 infants with gastroschisis and 103 weight-matched controls that were evaluated for early onset infection. RESULTS: Compared with the control group, there was a significantly increased percentage of infants with an I:T ratio > 0.2 in the gastroschisis group (43% vs. 12%, p < 0.001) and an increased percentage of infants exposed to greater than 5 days of antibiotics regardless of their I:T ratio (75% vs. 6%, p < 0.001). There were no episodes of culture positive early onset sepsis in either group. CONCLUSION: Our results indicate that I:T ratio is not a reliable marker of infection in gastroschisis, and suggest that empiric septic evaluation and antibiotic use, immediately following delivery in gastroschisis infants, may be unnecessary.

Perioperative glycaemic control for preterm infant with transient neonatal hyperglycaemia and gastroschisis.

BACKGROUND: Neonatal hyperglycaemia is a rare metabolic disorder. There are no reports of an association between neonatal hyperglycaemia and gastroschisis. CASE PRESENTATION: This report presents preoperative and intraoperative management of blood sugar in a low birth weight Thai preterm neonate with gastroschisis and a diagnosis of neonatal hyperglycaemia. The patient underwent an emergency, multi-staged, surgical repair under general anaesthesia. CONCLUSION: Anaesthesiologists should be aware of possible perioperative dysglycaemic conditions in these patients. Proper timing of surgery and appropriate preanaesthetic preparation are necessary to reduce the morbidity and mortality related to hyperglycaemia and gastroschisis. CONSENT: The patient's guardian has given consent for the case report to be published.

Probiotic Administration in Infants With Gastroschisis: A Pilot Randomized Placebo-Controlled Trial.

OBJECTIVES: Infants with gastroschisis often require long periods of gastric suctioning and hospitalization. The impact of these interventions on the intestinal microbiota and attempts to alter the microbial community have not been studied. We sought to determine how the intestinal microbiota is influenced by the current treatment of gastroschisis and whether alteration of the intestinal microbiota with a probiotic microbe will influence length of hospitalization. METHODS: We performed a randomized, placebo-controlled pilot study of administration of probiotic Bifidobacterium longum subsp. infantis in 24 infants with gastroschisis. The primary outcome was changes in the fecal microbiota, and the secondary outcome was length of hospital stay. RESULTS: Administration of the probiotic or placebo was well tolerated, even during the period of gastric suctioning. The overall microbial communities were not significantly different between groups, although analysis of the final specimens by family demonstrated higher Bifidobacteriaceae, lower Clostridiaceae, and trends toward lower Enterobacteriaceae, Enterococcaceae, Staphylococcaceae, and Streptococcaceae in the probiotic group. Clinical outcomes, including length of hospital stay, did not differ between groups. CONCLUSIONS: In this pilot study, there was significant in infants with gastroschisis that was partially attenuated by the administration of B longum subsp. infantis.

Treatment of bowel in experimental gastroschisis with a nitric oxide donor.

OBJECTIVE: To reduce the harmful effect of bowel exposure to amniotic fluid in gastroschisis, we used the nitric oxide (NO) donor S-nitrosoglutathione (GSNO) in an animal model of gastroschisis and assessed the ideal concentration for treatment of changes in bowel. STUDY DESIGN: Gastroschisis was surgically induced in rat fetuses on day 18.5 of gestation. The fetuses were divided into 5 groups (n = 12 animals/group): control (C), gastroschisis (G), gastroschisis + GSNO 5 µmol/L (GNO1), gastroschisis + GSNO 0.5 µmol/L (GNO2), and gastroschisis + GSNO 0.05 µmol/L (GNO3). On day 21.5 of gestation, fetuses were collected by cesarean delivery. Body and intestinal weight were measured and the bowels were either fixed for histometric and immunohistochemical study or frozen for Western blotting. We analyzed bowel morphometry on histological sections and expression of the NO synthase (NOS) enzymes by Western blotting and immunohistochemistry. Data were analyzed by analysis of variance or Kruskal-Wallis test when appropriate. RESULTS: Morphological and histometric measurements of weight, diameter, and thickness of the layers of the intestinal wall decreased with GSNO treatment, especially in the GNO3 group, when compared with the G group (P < .05). The expression of neuronal NOS, endothelial NOS, and inducible NOS decreased mainly in GNO3 group compared to the G group (P < .05), with no difference compared to C group (P > .05). CONCLUSION: Fetal treatment with 0.05 µmol/L GSNO resulted in significant improvement of bowel morphology in gastroschisis.

Corticosteroid effect upon intestinal and hepatic interleukin profile in a gastroschisis rat model.

PURPOSE: To evaluate the effect of corticosteroids on intestinal and liver interleukin profile in an experimental model of gastroschisis in fetal rats. METHODS: Sprague-Dawley rats at 19.5 days of gestation had its fetuses operated for the creation of gastroschisis. Two groups of fetuses were studied with and without maternal administration of dexamethasone. Each group was composed of fetuses who underwent gastroschisis (G), control fetuses without manipulation (C) and sham fetuses (S). A dosage of the following interleukins was carried out in fetal intestinal and liver tissues: IL-1, IL-6, IL-10, tumor necrosis factor-alpha (TNF-α) and interferon-gamma (IFN-γ). The differences between the groups and subgroups were tested by ANOVA with Tukey post-test, with significant values of p<0.05. RESULTS: Dexamethasone led to an increase in intestinal and liver IL-6 (p<0.05) and a decrease in intestinal TNF-α (p<0.001) in fetuses with gastroschisis. CONCLUSION: Corticosteroids had an effect on the intestinal interleukin profile and a small effect on the liver interleukin profile due to immunological immaturity of the fetus, and also of fetuses with gastroschisis. The steroid action may not be exclusively anti-inflammatory, but also pro-inflammatory, varying with time of pregnancy.

Corticosteroid effect upon intestinal and hepatic interleukin profile in a gastroschisis rat model / Efeito do corticoesteróide sobre o perfil das interleucinas intestinais e hepáticas no modelo de gastrosquise em ratos

PURPOSE: To evaluate the effect of corticosteroids on intestinal and liver interleukin profile in an experimental model of gastroschisis in fetal rats. METHODS: Sprague-Dawley rats at 19.5 days of gestation had its fetuses operated for the creation of gastroschisis. Two groups of fetuses were studied with and without maternal administration of dexamethasone. Each group was composed of fetuses who underwent gastroschisis (G), control fetuses without manipulation (C) and sham fetuses (S). A dosage of the following interleukins was carried out in fetal intestinal and liver tissues: IL-1, IL-6, IL-10, tumor necrosis factor-alpha (TNF-α) and interferon-gamma (IFN-γ). The differences between the groups and subgroups were tested by ANOVA with Tukey post-test, with significant values of p<0.05. RESULTS: Dexamethasone led to an increase in intestinal and liver IL-6 (p<0.05) and a decrease in intestinal TNF-α (p<0.001) in fetuses with gastroschisis. CONCLUSION: Corticosteroids had an effect on the intestinal interleukin profile and a small effect on the liver interleukin profile due to immunological immaturity of the fetus, and also of fetuses with gastroschisis. The steroid action may not be exclusively anti-inflammatory, but also pro-inflammatory, varying with time of pregnancy.

OBJETIVO: Avaliar a ação do corticosteroide no perfil de interleucinas intestinais e hepáticas no modelo experimental de gastrosquise em fetos de ratos. MÉTODOS: Ratas Sprague-Dawley com 19,5 dias de gestação tiveram fetos operados para criação de gastrosquise. Dois grupos de fetos foram estudados: com e sem administração materna de dexametasona. Cada grupo foi composto por fetos submetidos a gastrosquise (G), fetos controles sem manipulação (C) e fetos sham (S). Realizou-se a dosagem das seguintes interleucinas no tecido intestinal e hepático fetal: IL-1, IL-6, IL-10, fator de necrose tumoral-alfa (TNF-α) e interferon-gama (IFN-γ). As diferenças entre os grupos e subgrupos foram testadas pelo teste de ANOVA com pós-teste de Tukey, com valores significativos de p<0,05. RESULTADOS: A dexametasona levou a um aumento da IL-6 intestinal e hepática (p<0,05) e a uma diminuição do TNF-α intestinal (p<0,001) em fetos com gastrosquise. CONCLUSÃO: O corticosteróide apresentou efeito sobre o perfil de IL intestinal e pouco na hepática, devido a imaturidade imunológica dos fetos e também dos fetos com gastrosquise a ação do esteróide pode não ser exclusivamente anti-inflamatória, mas também pró inflamatória.

Gastrosquisis inviable neonatal / Non-viable neonatal gastroschisis

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Induction of fetal diuresis with intraamniotic furosemide injection reduces intestinal damage in a rat model of gastroschisis.

BACKGROUND/PURPOSE: Contact with amniotic fluid causes intestinal damage (ID) in fetuses with gastroschisis. Intraamniotic meconium has been shown to be responsible for ID, and ID has been shown to correlate with intraamniotic meconium concentrations. ID can be prevented by lowering the intraamniotic meconium concentration. A new method to lower intraamniotic meconium concentration might consist in the induction of fetal diuresis with intraamniotic diuretic injection. This hypothesis was tested in a rat model. MATERIALS AND METHOD: There were 4 experimental groups. CONTROL GROUP: Rat fetuses without any manipulation. Fetuses were harvested by cesarean section for examination at E21.5 (Term). SHAM GROUP: On E18.5, the hind limb of the rat fetuses were exteriorized by hysterotomy and replaced in the uterus. GASTROSCHISIS GROUP: Gastroschisis was surgically created in rat fetuses on E18.5, under a dissection microscope (16×). GASTROSCHISIS+FUROSEMIDE GROUP: After surgical creation of gastroschisis on E18.5, intraamniotic furosemide (5 mg/kg) was administered to the fetuses on E20. All fetuses were harvested on E21.5. RESULTS: There was no significant difference between intestinal serosal thicknesses of the control and sham groups. The serosal thickness was significantly higher in the gastroschisis group compared to the control group. In the gastroschisis+furosemide group, the intestinal serosal thickness was found significantly decreased compared with the gastroschisis group. CONCLUSION: Intraamniotic furosemide injection caused a substantial decrease in ID encountered in gastroschisis. The induction of fetal diuresis with intraamniotic furosemide injection seems promising as a prenatal treatment modality.

Hydrogel protection: a novel approach to reduce bowel inflammation in experimental gastroschisis.

OBJECTIVE: In gastroschisis there is herniation of the fetal bowel into the amniotic cavity that results in severe intestinal dysfunction. In order to reduce bowel exposure to amniotic fluid we used a hydrogel of N-isopropylacrylamide copolymerized with acrylic acid (P(NIPAAm-co-AAc)) to coat the herniated bowel through the use of a fibrin adhesive (Beriplast). STUDY DESIGN: Gastroschisis was created in fetuses of 31 pregnant Sprague-Dawley rats by evisceration of the bowel through a right paramedian incision in the abdominal wall on day 18.5 of pregnancy. The fetuses were separated in four groups of 12 fetuses: control (C), gastroschisis (G), gastroschisis+fibrin adhesive (GA) and gastroschisis+fibrin adhesive+dry hydrogel (GAH). Animals were harvested at day 21.5 of pregnancy and the hydrogel was removed. Fetuses and bowels were weighed and morphometric analysis was performed. Isoelectric focusing of the amniotic fluid determined its electrical charge. We evaluated the hydrogel swelling ratio (Q) in the amniotic fluid. Histological analysis and scanning electronic microscopy (SEM) of the bowel and hydrogel were performed. Our primary outcome was bowel intactness after hydrogel removal and our secondary outcome was the effectiveness of the hydrogel in protecting the bowel against amniotic fluid and its components. Differences among the groups were tested by the ANOVA and Tukey-Kramer post-test method and the statistical significance accepted was for p values <0.05. RESULTS: The mass of swollen hydrogel was 34 times the mass of dry hydrogel. Isoelectric focusing of the amniotic fluid showed that most of its proteins are negatively charged as the hydrogel. SEM showed that removal of the hydrogel did not damage bowel serosa. Bowel weight, diameter and wall thickness were similar between groups C and GAH but bowel diameter and wall thickness was significantly reduced in C and GAH compared to G and GA (p<0.001). CONCLUSION: The P(NIPAAm-co-AAc) hydrogel does not harm the bowel and provides a safe effective protection with reduction of bowel damage in gastroschisis.

Impact of corticosteroid on intestinal injury in a gastroschisis rat model: morphometric analysis.

BACKGROUND/PURPOSE: The goal in the treatment of gastroschisis is to prevent intestinal injury. Corticosteroids are known by their effects at the inflammatory response and by the improvement on the intestinal maturity. The authors evaluated the effects of maternal corticosteroid administration on the intestines of rats that underwent fetal gastroschisis. METHODS: A Correia-Pinto-modified gastroschisis rat model was used. Two groups were assessed: the control group (group 1) and the dexamethasone group (group 2). Each group was composed of control and sham fetuses, and fetuses with gastroschisis. Fetal body weight, intestinal weight, intestinal length, and protein were assessed. Histologic analysis involved measures of intestinal loop diameter, total intestinal wall, mucosa and submucosa, both circular and longitudinal muscle layers, and serosal thicknesses. Differences between groups and subgroups were tested by the analysis of variance method with a significant P value less than .05. RESULTS: Dexamethasone decreased in all the morphometric data except in the intestinal length. Dexamethasone increased the intestinal protein content in fetuses with gastroschisis, and control and sham fetuses. In both groups, all histologic parameters were increased in fetuses with gastroschisis (P < .0001). CONCLUSIONS: Dexamethasone caused a substantial decrease in intestinal weight in GFs, increased the intestinal protein content, and it may be useful in decreasing the intestinal damage of gastroschisis.

Effects of prenatal dexamethasone on the intestine of rats with gastroschisis.

BACKGROUND/PURPOSE: Intestinal lesions observed in gastroschisis (Gx) are accompanied by neonatal gastrointestinal dysfunction. This study examines the effects of transplacental dexamethasone on the eviscerated intestine of fetal rats with Gx. METHODS: Gx was created surgically in rat fetuses on gestational day 18, and the dams were treated either with 0.4 mg/kg intraperitoneal dexamethasone or with vehicle only on days 19 and 20. The intestine recovered on day 21 were processed for total DNA and protein. Immuno-histochemical staining for ki-67, TUNEL, and synaptophysin were used for assessing the proportions of proliferating and apoptotic cells and the density of intramural ganglia. Analysis of variance (ANOVA) was used for comparison among groups. Significance level was set at P less than.05. RESULTS: Body weight was reduced in Gx fetuses in comparison with controls. Intestinal weight per centimeter and mucosal and seromuscular layer thicknesses were increased in Gx and Gx + dexa groups. Total intestinal DNA was diminished in Gx animals but it was near normal in Gx + dexa ones. Total intestinal protein was similar in all groups. DNA and protein per centimeter of bowel were very increased in Gx animals but only slightly in Gx + dexa ones. Proliferating cells were decreased in Gx animals and increased in Gx+dexa ones, whereas the opposite was observed for apoptosis. Density of intramural ganglia was decreased significantly in both Gx groups. CONCLUSIONS: Late intrauterine exposure to dexamethasone of rat fetuses with Gx decreased wall thickening, normalized total DNA, and induced proliferation in the exposed bowel while limiting apoptosis. This medication could have some yet incompletely defined beneficial effects on the wall of the eviscerated bowel in Gx.

Induction of fetal diuresis with intraamniotic furosemide increases the clearance of intraamniotic substances: An alternative therapy aimed at reducing intraamniotic meconium concentration.

BACKGROUND/PURPOSE: Contact with amniotic fluid (AF) causes intestinal damage in gastroschisis. Intraamniotic meconium has been shown to be responsible for intestinal damage, and occurrence of this damage has been shown to depend on the concentration of intraamniotic meconium. When intraamniotic meconium concentration is lowered below threshold level by exchanging AF with saline in gastroschisis, intestinal damage can be prevented. Theoretically, induction of fetal diuresis with intraamniotic furosemide may increase AF volume and fetal swallowing rate, thus, increase absorption of AF by intestines; therefore, the clearance of meconium from the AF may increase. An experimental study was planned to investigate the effects of intraamniotic diuretic injection on the clearance of intraamniotic substances. METHODS: Pregnant rabbits on the 23rd to 25th gestational day were divided into 2 groups as furosemide and control. Technetium tc99m labeled "tin colloid" was injected into the amniotic cavity, and AF sample was taken 10 minutes later. Furosemide was injected into the amniotic cavity afterwards. Two and 6 hours later, AF samples were obtained. Intestines were harvested at the end of the study. Control group received intraamniotic saline instead of furosemide. Radioactivities of the AF samples and intestines were determined by gamma counter. Clearance of the radioisotope from AF and intestinal accumulation were calculated. RESULTS: The clearance of the radioisotope from AF was increased significantly in the furosemide group (n = 10) compared with the control group (n = 8; P <.01). Gastrointestinal accumulation of the radioisotope in the furosemide group was 4-fold higher than that the control group (P <.01). CONCLUSIONS: Induction of fetal diuresis with intraamniotic furosemide accelerates the clearance of intraamniotic substances. This is probably caused by increased urinary output rate, which increases AF volume and consequently results in increased fetal swallowing of AF. In the diseases like gastroschisis and myelomeningocele, in which the contact with AF causes tissue damage, the elimination of meconium from AF in a somewhat natural manner like this method, should be studied further because it may be an alternative minimal invasive in utero treatment modality.

Cisapride and caesarean section: their role in babies with gastroschisis.

OBJECTIVE: The objective of this study was to compare the neonatal postoperative course and morbidity for patients with gastroschisis who received cisapride with those who did not receive cisapride. STUDY DESIGN: Data were obtained by review of the medical records of all the patients with gastroschisis who were admitted to Sydney Children's Hospital between January 1984 and December 1995. Data were compared between 15 babies who received cisapride with 27 who did not. The mode of delivery and outcome of babies in whom gastroschisis was diagnosed antenatally was compared with those who were diagnosed at birth. RESULTS: Duration to the commencement of feeds, attainment of full feeds and the length of hospital stay were not statistically different between these two groups, with or without cisapride (p = > or = 0.1). There were more elective Caesarean sections in the antenatally diagnosed group compared to those detected at birth and the outcome of these two groups showed no statistically significant difference. CONCLUSIONS: Our study identified no benefit from cisapride therapy in babies with gastroschisis and also there was no benefit from elective Caesarean section for babies with antenatal diagnosis of gastroschisis.