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ORIGINAL ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 2  |  Page : 136-140  

Outcome of surgical condition of neonates who underwent surgery: A prospective study from a tertiary care center


1 Professor, Department of Pediatrics, Kamla Raja Hospital, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India
2 Associate Professor, Department of Pediatrics, Kamla Raja Hospital, Gwalior, Madhya Pradesh, India

Date of Submission20-Jul-2021
Date of Decision13-Dec-2021
Date of Acceptance14-Dec-2021
Date of Web Publication12-Jul-2022

Correspondence Address:
Ghanshyam Das
Department of Pediatrics, Kamla Raja Hospital, Gajra Raja Medical College, Gwalior, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1564_21

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   Abstract 


Background: The neonatal period is a highly vulnerable time for an infant, who is completing many of the physiologic adjustments required for extra- uterine survival. If the neonate has a coexisting pathology which needs surgery, this challenge is magnified. Neonatal surgical conditions are unique in their type because some require early diagnosis, prompt surgery and postoperative care to improve the survival and outcome. Objective: The aim of this study was to know the clinical profile of congenital surgical conditions and to estimate the burden and outcome in special new born care unit. Method: The study population include 138 surgical neonate admitted in special new born care unit, department of paediatrics, Kamla Raja Hospital, Gajra Raja Medical College, Gwalior (M.P.) from April 2017 to April 2018 including six month follow up period. Results: Total admission in special new born care unit were 5378 out of which 138 (2.5%) neonates of surgical condition were admitted in the study period. Incidence of neonatal surgical condition was found to be 8.48%. Surgery was performed in 57 (41.30%) neonates. The Commonest neonatal surgical condition was constituted by gastrointestinal system (39.13%). Among gastrointestinal system anomalies, tracheoesophageal fistula were 28.6% of total gastrointestinal system cases. The most common surgical condition encountered was meningomyelocele, 23.36% of total cases. The survival of neonatal surgical condition in hospital was 52.89% and after six month follow up was 26.08%. The overall mortality with neonatal surgical condition in this study was 73.91%. Maternal age, antenatal care, history of congenital malformation, socioeconomic status, mode of delivery, prematurity, type of admission, single or multiple surgical condition, inotropic and ventilation support, post operative complication were significantly associated with final outcome of neonatal surgical condition. Conclusion: High mortality was found in neonates suffering from surgical conditions. Commonest anomaly includes conditions of gastrointestinal tract. Maternal age more than 35 year, poor antenatal care, prematurity, vaginal delivery, extra mural neonate, multiple surgical condition, inotropic and ventilation support and post operative complications were associated with increased mortality.

Keywords: Congenital anomalies, neonatal surgical condition, neonates


How to cite this article:
Das G, Gupta V, Sharma N. Outcome of surgical condition of neonates who underwent surgery: A prospective study from a tertiary care center. Indian J Public Health 2022;66:136-40

How to cite this URL:
Das G, Gupta V, Sharma N. Outcome of surgical condition of neonates who underwent surgery: A prospective study from a tertiary care center. Indian J Public Health [serial online] 2022 [cited 2022 Aug 18];66:136-40. Available from: https://www.ijph.in/text.asp?2022/66/2/136/350648




   Introduction Top


The neonatal period is a highly vulnerable time for an infant, who is completing many of the physiologic adjustments required for extrauterine survival. The proposed Sustainable Development Goal target for child mortality aims to end, by 2030, preventable deaths of newborns, with all countries aiming to reduce neonatal mortality to at least as low as 12 deaths per 1000 live births. If the neonate has a coexisting pathology which needs surgery, this challenge is magnified. Neonatal surgical conditions are unique in their type because some require early diagnosis, prompt surgery, and postoperative care to improve the survival and outcome. Surgery on newborn poses a major challenge worldwide.[1],[2],[3] Despite improvement in surgical technique, technologies, and anesthesia, critical neonatal surgical conditions seem to be the main causes of morbidity and mortality, especially in neonatal population of india.[3],[4],[5] In developed countries, outcome of these cases are favorable because of availability of better care facility. In developing countries, however, neonatal surgery is still very challenging as it deals with a lot of problems due to the burden of other neonatal diseases. Neonatal surgery is often considered low priority, thereby, making newborn surgery to be associated with unacceptably high morbidity and mortality. The data regarding factors predicting outcome are still incomplete in India.

In view of this, the present study enrolled neonates admitted with surgical condition in Special Newborn Care Unit (S. N. C. U.), Kamla Raja Hospital, Gajra Raja Medical College, Gwalior (M. P.). The aim was to provide an insight into the status of surgical problems encountered in newborn unit and the outcome with at discharge and after 6-month follow-up.


   Methods Top


This was a prospective cross-sectional hospital-based study which included all neonates up to 28 days of life with surgical conditions including both intramural and extramural admitted in S. N. C. U. This Government hospital is only referral center for various neonatal surgical conditions. The parents or guardians of such babies who provided informed consent were enrolled. Institutional ethical committee clearance was obtained.

Inclusion criteria

Neonates born with surgical conditions who were admitted within <28 days of life.

Exclusion Criteria

Neonates with acquired surgical conditions (such as abscess, gangrene necrotizing enterocolitis). Neonates with minor surgical condition not affecting the quality of life significantly or those not requiring immediate correction/intervention.

Outcome

Were predictors of death within 30 days of surgery and in-hospital mortality, defined as death occurring after surgery during hospital stay.

Antenatal care (ANC) is a means the routine health control of presumed healthy pregnant women without symptoms (screening), to diagnose diseases or complicating obstetric conditions without symptoms and to provide information about lifestyle, pregnancy, and delivery. As per WHO, at least 8 visits will be there.

The antenatal factors contributing to neonatal surgical cases were recorded. Data were collected and categorized on the basis of sex, intramural and extramural deliveries, birth weight, gestational age, at presentations mode of delivery, type of gestation (single/twins), maternal age, parity, body mass index age at presentation, previous history of congenital malformation, maternal ultrasonography, socioeconomic status, ANC, folic acid supplementation, single or multiple surgical condition, need for inotropes, ventilation support, postoperative complications. Kuppuswamy's socioeconomic status scale was used for assessing the socioeconomic class, subcategory upper middle and lower middle merged to form middle class, and subcategory upper lower and lower merged to form lower class. Data were entered in an Excel spreads sheet and analyzed by micro soft excel. Categorical data were analyzed using the Chi-square test. P < 0.05 was regarded as significant and results were given up to two decimals.


   Results Top


A total of 138 neonates with surgical conditions were admitted during study period. Among the total admission of neonatal surgical condition, 80 (57.97%) were males and 58 (42.03%) were females. Average age on admission was 3 days (range 1 day to 28 days). The average birth weight was 2100 g (range 900 g to 4400 g). [Table 1] shows that among the total admission of neonatal surgical condition, 81 (58.70%) were low birth weight and 57 (41.30%) were normal birth weight. Total mortality was 26.09% among the all study subjects. Prematurity significantly associated with poor outcome with statistically significance (P = 0.01), out of 40 premature neonates, 36 (65.3%) died. Cesarean delivery significantly associated with good outcome with statistically significance (P ≤ 0.01), out of 33 cesarean section delivered surgical condition neonates, 14 (42.42%) were successfully managed. Previous history of congenital malformation in sibling was significantly associated with good outcome with statistically significance (P ≤ 0.01). Extramural neonate significantly associated with poor outcome with statistically significance (P = 0.02), among 110 surgical neonate of extramural unit, 85 (77.27%) died. Lower socioeconomic status with poor outcome was statistically significantly associated with mortality (P = 0.03), out of 111 surgical neonate of low socioeconomic status, 87 (78.37%) died. Maternal age more than 35 years significantly associated with poor outcome (P = 0.03), out of 48 surgical neonate with maternal age more than 35 years, 39 (81.25%) died and 4 (8.33%) were successfully managed. History of poor ANC significantly associated with poor outcome with statistically significance (P = 0.02), out of 95 surgical neonate with no maternal history of ANC, 77 (81.05%) died. Need for ventilation and inotropes support significantly associated with poor outcome (P = 0.0001), out of 71 surgical neonate who need ventilation and inotropes support, 69 (97.18%) died. Postoperative complication significantly associated with poor outcome with (P ≤ 0.01), out of 32 surgical neonate with postoperative complication, all 27 (100%) died. Regular follow-up in outpatient department significantly associated with good outcome (P ≤ 0.01), out of 32 surgical neonates with follow-up done only by telephonic means, all 32 (100%) died and among the total 41 neonate with regular follow-up, 27 (65.85%) were successfully managed and 5 (12.20%) died, 9 (21.95%) not operated till follow-up.

[Table 2] shows that most common neonatal surgical condition was constituted by gastrointestinal system observed in 39.13% cases. Next in order of frequency was central nervous system in 34.78% cases, followed by musculoskeletal system in 10.86% cases, then cardiovascular system in 7.24% cases, followed by abdominal system in 2.89% cases, succeeded by urogenital system in 2.17% cases, then or facial malformation in 1.44% cases and lastly lymphatic system in 1.44% cases. Gastrointestinal system contributing the maximum operated (50.87% of total operated) cases, maximum managed (37.03% of total managed) cases and maximum death (43.13% of total death). Central nervous system contributed the maximum number of cases that were not operated till follow-up, i.e., 44.44% of total cases.
Table 1: Neonatal characteristics and their outcome

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Table 2: System wise distribution of neonatal surgical conditions and their final outcome

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Tracheoesophageal fistula was the most common cause of gastrointestinal neonatal surgical condition, observed in 57.40% of total gastrointestinal cases. The most frequent neonatal surgical condition encountered was meningomyelocele, observed in 25.36% of total neonatal surgical admission. Among all neonatal surgical condition admission, surgical interventions were done in 41.31% cases.

Among all neonatal surgical condition cases, better postoperative survival was obtained in anorectal malformation (42% cases). Rate of survival in operated case of neonatal surgical conditions was 42.10% and in nonoperated cases was 14.81% after 6-month follow-up. The overall survival of neonatal surgical condition in hospital was 52.89% and after 6 months of follow-up, it was 26.08%. The mortality of neonatal surgical condition after 6-month follow-up was 73.91%.

Multiple surgical conditions were present in 17 (12.31%) cases, out of which only 1 (6.8%) case was managed successfully, 15 (88.24%) died and 1 (6.8%) was not operated till follow-up. Death rate was more in neonates with multiple surgical conditions when compared to newborn with single surgical condition.


   Discussion Top


In our study, 8.48% of the Neonatal Intensive Care Unit admissions were due to neonatal surgical conditions. It was higher than 3.6% reported in a study by Shah et al.[6] in Saurashtra India, however, the study was over 8-year period as against the present study that was only 1-year period. In a study by Ugwu and Okoro[7] in Nigeria, this incidence was 6.2%.

In the present study, it was observed that prematurity found to be one of the important factors statistically significant that determine the final outcome of surgical cases (P = 0.01). In the present study, less case was successfully managed and more death occurred in premature in comparison to full-term neonate. Similar results were obtained by Ugwu and Okoro[7] and Shah et al.[6]

Cesarean section delivered neonates were having good outcome of neonatal surgical condition. This difference of cesarean and normal delivered neonate was statistically significant (P ≤ 0.01).

Neonate with history of congenital malformation in siblings significantly associated with good outcome of neonatal surgical condition (P ≤ 0.01). In extramural born neonate significantly associated with poor outcome of neonatal surgical condition (P = 0.02). Similar results obtained by Ugwu and Okoro[7] and Hedstrom et al.[8]

In comparison to middle socioeconomic class surgical condition neonate, more deaths were observed in low socioeconomic class neonate. This difference of socioeconomic status was statistically significant (P = 0.03). Similar observations were obtained by Vrijheid et al.[9] (2000) and Pawluk et al.[10]

Neonates with maternal with age more than 35 years, significantly associated with poor outcome of neonatal surgical conditions (P = 0.03). Maternal history of ANC significantly associated with good outcome (P = 0.02).

Surgical condition neonate with history of need of inotropes and ventilation support significantly associated with poor outcome of neonatal surgical condition (P ≤ 0.01). Among the total operated cases of neonatal surgical condition, 47.38% develop postoperative complication. In comparison to surgical condition neonate with no postoperative complication, more death (100%) were observed in neonate who develop postoperative complication. This difference was statistically significant (P ≤ 0.01). It was higher than 33.33% reported in a study by Catré et al.[11] In a study by Ugwu and Okoro[7] in Nigeria, this incidence was 59% and 47% death were due to postoperative complication. In a study by Osifo et al.[12] observed, 55.6% death were due to postoperative septicemia.

Surgical condition neonate with regular follow-up in outpatient department significantly associated with good outcome of neonatal surgical condition (P ≤ 0.01).

Most common neonatal surgical condition was constituted by gastrointestinal system observed in 39.13% cases. Similar results were obtained by Virupakshappa et al.,[13] Shah et al.,[6] and Yadav et al.[14] Tracheoesophageal fistula was the most common cause of gastrointestinal neonatal surgical condition observed in 57.40% of the total gastrointestinal cases. Similar results were obtained in study by Shah et al.[6]

In the present study, surgical interventions were possible in only 41.31% cases and better postoperative survival was obtained in anorectal malformation (42% cases). Similar results were obtained by Virupakshappa et al.[13]

Rate of survival in operated case of neonatal surgical conditions was 42.10% (after 6-month follow-up) and in nonoperated cases were 14.81% (after 6-month follow-up). It was lower than 48.70% reported in a study Opara et al.[15] (2014). A study by Yadav et al.[14] observed 70% postoperative survival rate.

The overall survival of neonatal surgical condition in hospital was 52.89% and after 6 months of follow-up, it was 26.09%. It was lower than 65% reported in a study Gangopadhyay et al.[16] It was higher than 48% reported in a study by Shah et al.[6] with sample size 328 in a tertiary center of Saurashtra India.

The overall mortality of neonatal surgical condition in hospital was 47.11% and after 6-month follow-up, it was 73.91%. It was lower than 51.20% reported by Shah et al.[6] It was higher than 42.60% reported by Ugwu and Okoro.[7]

Most of the studies done for surgical congenital malformations are retrospective studies while our was prospective with long-term follow-up, not seen in other studies.


   Conclusion Top


The incidence of neonate with congenital surgical malformations is quite high in new born as admitted to S. N. C. U. and is an independent risk factor for mortality. These neonates require urgent medical and surgical inter venations during their hospital stay to improve their outcome.

Limitation

In this study, telephonically follow-up is obtained who has not able to come to hospital because of lack of transport from periphery, poor socioeconomic status, social pressure from family member, these factors affect the regular follow-up. This institute has follow-up only of 30%–35% of operated cases.

Other surgical conditions follow-up has not included because of neonate admitted in other department and followed up there postoperatively.

Key messages

What is already known?

  • Prematurity, postoperative complications, extramural neonates, and lower socioeconomic status were significantly associated with poor outcome in neonates with surgical condition
  • ANC was associated with good outcome of neonatal surgical condition.


What this study adds?

  • Cesarean delivery, previous history of congenital malformation in siblings and surgical intervention were associated with good outcome of neonatal surgical cases
  • Maternal age more than 35 years, multiple surgical conditions and need for ventilation and inotropes supports were associated with poor outcome of neonatal surgical conditions
  • Antenatal ultrasonography was not being utilized for in utero transfer of surgical neonate to referral facility
  • There is a need for prolong follow-up to review the ultimate survival of these operated surgical cases.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Virupakshappa PM, Rajendra N. Burden and spectrum of neonatal surgical diseases in a tertiary hospital: A decade experience. Int J Comtemporary Pediatr 2018;5:798-803.  Back to cited text no. 13
    
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Yadav P, Mishra A, Raina VK. Neonatal surgical emergencies in a tertiary care center. IJSS J Surg 2015;1:5-9.  Back to cited text no. 14
    
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Opara PI, Ujuanbi AS, Okoro PE. Surgiacl admissions in a newborn unit in a low resource setting, challenges in management and outcomes. J Neonatal Biol 3:132. doi:10.4172/2167-0897.1000132.  Back to cited text no. 15
    
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