Dorsal penile nerve block vs topical placebo for circumcision in low-birth-weight neonates.

OBJECTIVE: To investigate the efficacy and safety of dorsal penile nerve block (DPNB) and eutectic mixture of lidocaine (EMLA) for palliation of pain associated with circumcision in low-birth-weight infants. DESIGN: Randomized, blinded, controlled trial. SETTING: Intensive care nursery (step down unit) at Georgetown University Medical Center, Washington, DC. PARTICIPANTS: Fifty neonates with weights of 1600 to 2500 g at the time of circumcision who were discharged from the hospital between May 1994 and June 1995 were randomly assigned to the DPNB, EMLA, or control group. Twenty-five infants who were otherwise eligible were excluded because of parental refusal of consent to participate. INTERVENTIONS: Infants in the DPNB and EMLA groups received anesthesia with subcutaneous injection of 1% lidocaine hydrochloride or topical EMLA, respectively. The control group received sham anesthesia with topical placebo (acid mantle cream). MAIN OUTCOME MEASURES: Changes in physiologic variables (heart rate, blood pressure, oxygen saturation, and respiratory rate) and behavioral score 20 minutes before, during, and 5 and 20 minutes after circumcision between DPNB and control groups. Surgical complications and adverse effects were also monitored. RESULTS: Fifty infants were enrolled in the study: 19 randomized to the DPNB group, 19 to the control group, and 12 to the EMLA group. Enrollment into the EMLA group was suspended early because of redness and blistering of the foreskin in 2 infants, and this entire group was excluded from further analysis. The clinical course was similar in all groups of infants. All circumcisions were performed without complication or technical difficulty. Statistically significant differences were noted in heart rate, respiratory rate, and behavioral score when comparing the DPNB group with controls during and after circumcision. CONCLUSION: Dorsal penile nerve block is safe and effective in controlling pain associated with circumcision in low-birth-weight infants.

Complications of intrauterine placement of a vesicoamniotic shunt.

BACKGROUND: Fetal obstructive uropathies complicated by severe oligohydramnios can cause neonatal death due to renal dysplasia and pulmonary hypoplasia. CASE: A 31-year-old multigravida was referred at 19.6 weeks with sonographic evidence of fetal megacystis and bilateral hydroureteronephrosis, and severe oligohydramnios. A vesicoamniotic shunt was placed for urinary diversion. Complications included shunt migration, intestinal evisceration, amniorrhexis, preterm labor, and preterm delivery. Bowel characteristics were assessed by measuring the intestinal lumen diameter for evidence of obstruction. The lumen diameter remained stable at 3-5 mm, and the luminal wall remained stable at 2.5 mm. After birth at 31 weeks, the infant underwent exploratory laparotomy and extraction of malpositioned shunts, vesicostomy, and closure of abdominal wall defect. He was discharged at 61 days of life after resolution of neonatal pulmonary and infectious complications. CONCLUSION: Operative management of complete fetal obstructive uropathy is beneficial despite potential complications.

In utero nephrostomy catheter placement.

In utero diagnosis of severe oligohydramnios and fetal ureteral pelvic outlet obstruction resulted in the placement of nephrostomy catheters in two fetuses. The amniotic fluid index improved, mid-chest thoracic circumference increased and renal calyceal dilation decreased in both patients. Both neonates had evidence of pulmonary hypoplasia but survived. This new technique offers an alternative for antenatal management of obstructive uropathy when the bladder is not accessible or is distal to the site of the obstruction.

Prenatal diagnosis of trisomy 12 mosaicism: physical and developmental follow-up.

Follow-up evaluations were performed on a child at the ages of 2 years 8 months and also at 5 years who had been found on prenatal amniocentesis to be mosaic for trisomy 12. Eight of 36 colonies (22 per cent) were trisomy 12 at amniocentesis, with the remaining colonies showing a normal female karyotype. Cord blood, amnion, chorion, placental, and skin fibroblast chromosome studies failed to show any further evidence of a trisomy 12 cell line. At her evaluations, the child had normal physical and neurological findings. Psychomotor development was appropriate for age on screening.

Ultrasound guidance of suprapubic bladder aspiration in neonates.

We performed a prospective, randomized trial comparing ultrasound guidance of suprapubic bladder aspiration with unguided aspiration. The acquisition of urine improved with ultrasound guidance from 60% to 96.4%. The number of needle insertions decreased and the amount of urine obtained increased. Ultrasonography is a useful tool for bladder aspiration.

Rapid determination of fetal sex by deoxyribonucleic acid amplification of Y chromosome-specific sequences.

Rapid fetal sex tests use either dot blot hybridization to Y chromosome-specific (male) repeat sequences or polymerase chain reaction deoxyribonucleic acid amplification of these Y-specific sequences. We have performed 35 fetal sex determinations, 16 by dot blot alone, 13 by polymerase chain reaction alone, and 6 by dot blot and polymerase chain reaction on samples of fetal blood, amniotic fluid, and chorionic villi. All results have been confirmed by karyotyping. Dot blots have given false-positive "male" results three times. In contrast, the polymerase chain reaction has correctly determined fetal sex in every case, even when the dot blot was in error. The Y-specific polymerase chain reaction has been applied to fetal deoxyribonucleic DNA with a chromosome 15; Y translocation to identify the origin of the translocated material. Thus the polymerase chain reaction appears to be a reliable method to rapidly determine fetal sex that also can be used diagnostically to identify translocated Y-chromosomal material.

Fetal surgery.

Interest in correcting fetal pathology before birth has been stimulated by advancing experimental technology and improvements in the ability of ultrasound to look into the uterus. In this article, diagnosis, management and treatments of three congenital defects, hydronephrosis, ventriculomegaly, and diaphragmatic hernia are discussed. The future of fetal in utero surgery also is considered.