Folic acid supplementation and risk for fetal abdominal wall defects in China: results from a large population-based intervention cohort study.

Folic acid (FA) can reduce the risk for selected birth defects other than neural tube defects. We examined whether FA has preventive effects against fetal abdominal wall defects (AWD) in a unique intervention cohort in China. Birth outcomes of 247 831 singleton births from a population-based cohort study with detailed pre-conceptional FA intake information were collected in China in 1993-1996. Information on births at 20 complete gestational weeks, including live births, stillbirths and pregnancy terminations, and all structural birth defects regardless of gestational week were recorded. The birth prevalence of omphalocele, gastroschisis and total fetal AWD was classified by maternal FA supplementation. The prevalence of total AWD was 4·30 per 10 000 births among women who took FA compared with 13·46 per 10 000 births among those who did not take FA in northern China and 6·28 and 5·18 per 10 000 births, respectively, in southern China. The prevalence of omphalocele was 0·54 per 10 000 births among women who took FA compared with 3·74 per 10 000 births among those who did not take FA in northern China and 1·79 and 1·44 per 10 000 births, respectively, in southern China. FA supplementation significantly prevented total AWD in multivariate analysis (relative risk 0·26, 95 % CI 0·11, 0·61) in northern China, although no preventive effect of FA on AWD was observed in southern China. FA supplementation successfully reduced the prevalence of AWD in northern China.

Prevalence trends of selected major birth defects: A multi-state population-based retrospective study, United States, 1999 to 2007.

BACKGROUND: We evaluated selected birth defects over a 9-year period to assess prevalence trends by selected maternal and infant factors. METHODS: Data were pooled from 11 population-based birth defects surveillance programs in the United States for children born between 1999 and 2007. Overall prevalence, as well as 3-year interval prevalence, was calculated for 26 specific birth defects, stratified by maternal age, maternal race/ethnicity, and infant sex. Average annual percent change (AAPC) was calculated for each birth defect. Poisson regression was used to determine change in AAPC, and joinpoint regression to identify breakpoints and changes in slope for prevalence of each defect over time. RESULTS: Between 1999 and 2001 and 2005 and 2007, four birth defects increased by 10% or more: coarctation of the aorta (17%), gastroschisis (83%), omphalocele (11%), and Down syndrome (10%). Among mothers <20 years of age, the gastroschisis AAPC increased 10.1% overall and, cross-classified by maternal race/ethnicity, the AAPC for mothers <20 years increased 9.2%, 25.7%, and 7.7% among non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic mothers, respectively. A small increase in Down syndrome (AAPC 4.4%) was found for NHB mothers ≥35 years. CONCLUSION: No significant trends in prevalence were identified for most birth defects. Gastroschisis prevalence increased significantly among NHW and NHB mothers <20 years of age, with the greatest increases in NHB mothers. Prevalence of Down syndrome among NHB mothers ≥35 years also increased slightly. Stratified results may suggest avenues of research in birth defect etiology and in evaluating prevention efforts. Birth Defects Research 109:1442-1450, 2017.© 2017 Wiley Periodicals, Inc.

Self-reported maternal cigarette smoke exposure during the periconceptional period and the risk for omphalocoele.

BACKGROUND: We investigated whether maternal exposure to cigarette smoke was associated with omphalocoele and whether periconceptional folic acid modified the association. METHODS: : We analysed data from the National Birth Defects Prevention Study on omphalocoele case (n = 301) and control (n = 8135) mothers for infants born from 1997 through 2007. Mothers who reported active smoking or exposure to second-hand smoke during the periconceptional period (1 month before conception to 3 months after) were considered exposed. Those who reported use of folic acid supplements during the same period were considered supplement users. Odds ratios and 95% confidence intervals were estimated using multivariable logistic regression adjusted for alcohol use, preconception body mass index, and race/ethnicity. RESULTS: One hundred fifteen (38.2%) case and 2592 (31.9%) control mothers reported exposure to cigarette smoke during the periconceptional period. Adjusted odds ratios [95% confidence intervals] were 1.19 [0.94, 1.53] for any smoke exposure, 0.87 [0.54, 1.40] for active smoking, 1.38 [1.00, 1.90] for second-hand smoke exposure, and 1.16 [0.80, 1.67] for both exposures combined. No dose-response relationship was observed. Folic acid-containing supplements did not reduce the risk for omphalocoele among women with active or second-hand smoke exposure. CONCLUSIONS: Self-reported active maternal smoking, with or without exposure to second-hand smoke, during the periconceptional period was not associated with omphalocoele. In contrast, there was a possible association with periconceptional exposure to second-hand smoke.

Laparoscopic Tenckhoff catheter insertion: a retrospective study over 6 years.

INTRODUCTION: Peritoneal dialysis via Tenckhoff catheter predisposes to hernia formation due to both local and systemic factors. Another important complication of peritoneal catheter insertion includes infection, which can prompt removal of the catheter. METHODS: We performed a retrospective study between January 2005 and July 2011 of 61 patients who underwent laparoscopic placement of a Tenckhoff catheter and peritoneal dialysis at our institution using a single-port technique. We analysed complications of Tenckhoff insertion, specifically infection and the formation of hernias requiring operative management. RESULTS: Infections noted in our patients included peritonitis (10%) and exit-site infection (5%). Of the five patients who required re-insertion of Tenckhoff catheter, four were for infective complications. A total of seven hernias developed in five (8%) of patients, mostly inguinal or umbilical near the Hassan port entry site. DISCUSSION: With infection and hernia formation being the main contributors to failure of the procedure, actively addressing the entry site and areas predisposed to hernia formation, observing aseptic technique and meticulous attention to early signs of complications during follow-up are vital to improve success rates. The outcomes of the laparoscopic single-port insertion technique shows promise compared with conventional Tenckhoff catheter insertion techniques.

Pharmacologic treatment of hyperthyroidism during pregnancy.

Clinical hyperthyroidism has been associated with an increased risk of maternal, fetal, and neonatal complications. The available antithyroid drugs are methimazole/carbimazole and propylthiouracil. Several case reports and some epidemiologic studies suggest that methimazole/carbimazole exposure during the first trimester of pregnancy is associated with an increased risk of congenital malformations, including ectodermal anomalies, choanal atresia, esophageal atresia, and omphalocele. However, the absolute risk appears to be very small, and it remains unclear whether the association is driven by the maternal disease, the medication, or the combination of both factors. Propylthiouracil exposure has not been associated with an increased risk of congenital malformations and is the recommended drug during the first trimester of pregnancy. Since propylthiouracil-induced hepatotoxicity has been reported in approximately 0.1% of exposed adults and the number of case-reports of severe liver injury is increasing, treatment with low dose methimazole during the second and third trimesters should be considered. Until now, there has been no evidence that children prenatally exposed to methimazole/carbimazole or propylthiouracil have an increased risk of neurodevelopmental delay.

Incisional hernia in patients at risk: can it be prevented?

INTRODUCTION: Incisional hernia is a long-term complication of laparotomy. Its exact frequency varies according to different authors, but is always around 10-15%. There are patients who present with systemic associated diseases [chronic obstructive pulmonary disease (COPD), obesity, severe cardiopathies, immunodeficiencies, etc.] that favour or increase the risk of appearance of an incisional hernia. The aim of the present study was to assess whether the prophylactic placement of a polypropylene mesh in patients at risk can reduce or avoid the appearance of an incisional hernia. MATERIALS AND METHODS: Seventy-two selected patients with clear risk factors and colon pathology underwent surgical intervention through median infraumbilical laparotomy. During laparotomy the preperitoneal space was dissected at a point where a low-molecular weight polypropylene mesh was to be placed when closing the peritoneum. Meshes were about 7-8 cm wide and had a variable length that depended on the length of the surgical incision. Of the 72 patients, 41 were obese (BMI > 30 kg/m(2)), 45 presented with COPD, and 42 with colorectal neoplasia; 29 patients had two risk factors, and 15 had three risk factors. The mesh was held in place with polypropylene stitches in 28% of cases, and with fibrin glue in 72% of cases. RESULTS: All patients were assessed by a protocol that included interview, examination of the surgical wound, and abdominal CT scan. Follow-up was between 3 and 5 years. There were no noteworthy complications or operative mortality. No mesh had to be removed in any patient. Two patients developed liver metastasis, and in a second surgery the good condition of the abdominal wall and the absence of hernia were confirmed. Twenty patients required postoperative chemotherapy. Two patients died at 37 and 43 months after surgery because of progression of the neoplastic disease. Fourteen patients were monitored for more than 5 years after surgery, and 46 patients were monitored for 48 months. None of the 72 patients developed an incisional hernia. CONCLUSION: Prophylactic use of a low-molecular-weight polypropylene mesh in abdominal surgery may be useful for the prevention of incisional hernia.

Ketamina vs. fentanil como coadyuvantes en la anestesia epidural en pacientes sometidos a hemioplastías inguinales o umbilicales en el Hospital Antonio Lenin Fonseca, septiembre 2007 enero 2008 / Ketamina vs. fentanil like helping in the anesthesia epidural in subjected patients to hemioplastías inguinales or umbilical in the Hospital Antonio Lenin Fonseca, September 2007 January 2008

Se efectuó un estudio tipo ensayo clínico controlado, ciego, con el propósito de comparar ketamina con el Fentanil en la prolongación de la analgesia postoperatoria luego de ser administrados por vía epidural como fármacos coadyuvantes en la anestesia neuroaxial (Bloqueo epidural).Cuarenta y dos pacientes constituyeron la muestra, distribuyéndose en tres grupos de 14 pacientes cada uno, a todos los grupos se les administró Bupivacaina al 0.5 porciento mas Epinefrina 1: 200,000 75 mg como anestésico local, la diferencia radicó en el fármaco coadyuvante, para el grupo A fue ketamina 30 mg, en el grupo B Fentanil 100 ug y por ultimo el grupo C Bupivacaina 0.5 porciento más epinefrina 1:200,000. La duración de la analgesia resulto mayor en el grupo de la Ketamina con un promedio en minutos de 432 seguido del Fentanil con 372 minutos y por ultimo los pacientes que se les aplico Bupivacaina con 257 minutos de analgesia postoperatoria. Como conclusión la ketamina demostró ser mejor fármaco como coadyuvante en la anestesia epidural ya que prolongo mas la analgesia postoperatoria, sin embargo el Fentanil al ser comparado con el grupo de Bupivacaina logro mostrar que prolonga mas la analgesia que cuando solo se aplica Bupivacaina, por lo cual se contara con nuevas alternativas para manejar la analgesia postoperatoria, dada la eficacia de la Ketamina...

Topical applications of chlorhexidine to the umbilical cord for prevention of omphalitis and neonatal mortality in southern Nepal: a community-based, cluster-randomised trial.

BACKGROUND: Omphalitis contributes to neonatal morbidity and mortality in developing countries. Umbilical cord cleansing with antiseptics might reduce infection and mortality risk, but has not been rigorously investigated. METHODS: In our community-based, cluster-randomised trial, 413 communities in Sarlahi, Nepal, were randomly assigned to one of three cord-care regimens. 4934 infants were assigned to 4.0% chlorhexidine, 5107 to cleansing with soap and water, and 5082 to dry cord care. In intervention clusters, the newborn cord was cleansed in the home on days 1-4, 6, 8, and 10. In all clusters, the cord was examined for signs of infection (pus, redness, or swelling) on these visits and in follow-up visits on days 12, 14, 21, and 28. Incidence of omphalitis was defined under three sign-based algorithms, with increasing severity. Infant vital status was recorded for 28 completed days. The primary outcomes were incidence of neonatal omphalitis and neonatal mortality. Analysis was by intention-to-treat. This trial is registered with , number NCT00109616. FINDINGS: Frequency of omphalitis by all three definitions was reduced significantly in the chlorhexidine group. Severe omphalitis in chlorhexidine clusters was reduced by 75% (incidence rate ratio 0.25, 95% CI 0.12-0.53; 13 infections/4839 neonatal periods) compared with dry cord-care clusters (52/4930). Neonatal mortality was 24% lower in the chlorhexidine group (relative risk 0.76 [95% CI 0.55-1.04]) than in the dry cord care group. In infants enrolled within the first 24 h, mortality was significantly reduced by 34% in the chlorhexidine group (0.66 [0.46-0.95]). Soap and water did not reduce infection or mortality risk. INTERPRETATION: Recommendations for dry cord care should be reconsidered on the basis of these findings that early antisepsis with chlorhexidine of the umbilical cord reduces local cord infections and overall neonatal mortality.

Occurrence of omphalocele in relation to maternal multivitamin use: a population-based study.

OBJECTIVE: We evaluated the association between mothers' use of multivitamin supplements and their infants' risk for omphalocele, a congenital anomaly of the abdominal wall. Omphalocele can occur in certain multiple congenital anomaly patterns with neural tube defects, for which a protective effect of multivitamins with folic acid has been demonstrated. METHODS: We used data from a population-based case-control study of infants born from 1968-1980 to mothers residing in metropolitan Atlanta. Case-infants with nonsyndromic omphalocele (n = 72) were actively ascertained from multiple sources. Control-infants (n = 3029), without birth defects, were selected from birth certificates by stratified random sampling. RESULTS: Compared with no use in the periconceptional period, periconceptional use of multivitamin supplements (regular use from 3 months before pregnancy through the first trimester of pregnancy) was associated with an odds ratio for nonsyndromic omphalocele of 0.4 (95% confidence interval [CI]: 0.2-1.0). For the subset comprising omphalocele alone or with selected midline defects (neural tube defects, hypospadias, and bladder/cloacal exstrophy), the odds ratio was 0.3 (95% CI: 0.1-0.9). These estimates were similar when the reference group also included women who began using multivitamins late in pregnancy (during the second or third month of pregnancy). The small number of participants limited the precision of subgroup analyses and translated into wide confidence intervals that included unity. CONCLUSIONS: Periconceptional multivitamin use was associated with a 60% reduction in the risk for nonsyndromic omphalocele. These findings await replication from additional studies to confirm the findings, generate more precise estimates, and detail possible mechanisms of actions.

Assessment of the umbilical cord outside of the delivery room. Part 2.

The umbilical cord is crucial to the growth and development of the fetus. Careful inspection in the delivery room and throughout the newborn period is essential. Part 1 of this 2-part series, entitled "Look Before You Clamp: Delivery Room Examination of the Umbilical Cord" (Advances in Neonatal Care, Vol. 2, No. 1, pp 19-26), reviewed umbilical problems that present in the delivery room. A number of subtle but significant umbilical cord abnormalities present outside the delivery room. These abnormalities will be the focus of Part 2 of this series. A review of the embryologic development of the umbilical cord enhances the clinician's understanding of umbilical abnormalities that present in the newborn period. The process of umbilical cord separation is outlined. Conditions associated with delayed cord separation are discussed. A systematic approach to the physical examination of the umbilicus is offered, with an emphasis on early detection of abnormalities. Common and uncommon physical findings, such as omphalitis, periumbilical necrotizing fascitis, vitelline duct remnants, and urachal anomalies are presented along with select photographs. A brief discussion of the clinical implications for newborn care is provided for the practicing clinician.

Impact of antenatal diagnosis on incidence and prognosis in abdominal wall defects.

The authors review data from the Congenital Malformation Registry in South East Thames regarding fetal abdominal wall defects. Over 24 months, 80 cases were observed (40 gastroschisis, 40 exomphalos). Live-born infants with gastroschisis had few associated anomalies and an excellent prognosis (83% survival rate). Exomphalos is associated with an increased rate of life-threatening anomalies and chromosomal defects. The latter cases often are terminated prenatally. If these cases are excluded, the 1-year survival rate for liveborn infants with exomphalos is favorable (close to 80%). Fetuses in whom gastroschisis and exomphalos are identified by ultrasonography but who have no associated life-threatening chromosomal anomalies should have a favorable prognosis.

The Pelosi technique of full-thickness cannula site closure.

We developed a simplified technique for closing laparoscopic cannula sites. Its advantages are simplicity, speed, reproducibility, and cost-effectiveness. It requires no laparoscopic assistance or specialized instruments.