Indomethacin-induced reduction in neonatal piglet mesenteric blood flow is blunted by dopexamine

A case report of a low-birth-weight infant with a subcapsular liver hematoma and spontaneous bowel perforation

This case report describes a 27-week, 1040-g infant, whose mother presented with an acute abruption and fetal distress prompting emergency cesarean birth. The birth was further complicated by fetal malposition, manual version, birth trauma, and perinatal depression requiring intubation, ventilation, and chest compressions. On day of life (DOL) 7, the infant suddenly deteriorated with cardiovascular collapse and severe coagulopathy. Coexisting spontaneous bowel perforation (SBP) and ruptured subcapsular liver hematoma (SLH) were confirmed operatively. Although survival with ruptured SLH is rarely reported, with aggressive medical and surgical management, this infant survived and was discharged home at 43 weeks postconceptual age. SBP may occur silently; pneumoperitoneum may be an incidental finding. Conversely, rupture of an SLH typically presents with a sudden clinical deterioration. The common predisposing factor for both conditions is low birth weight (LBW). A review of the known and proposed risk factors, clinical signs and symptoms, pathophysiology, and treatment of both SBP and SLH are provided. A literature review highlighting the potential impact of drug exposures (indomethacin, hydrocortisone, and low molecular weight heparin) is provided, along with a discussion of the implications for clinical practice and research.

Indomethacin-associated bowel perforations: a study of possible risk factors

BACKGROUND

The association between indomethacin administration and bowel perforation in premature infants is well known. The goal of this study was to examine possible risk factors for this complication.

METHODS

Fifteen cases of indomethacin-associated bowel perforation occurred from 1993 to 1996. All had a birth weight < or = 1,100 g. These patients were compared with a control group of 51 infants who were cared for contemporaneously, had birth weights < or = 1,100 g and received indomethacin.

RESULTS

Survival rate in the control group was 96%. For the group with perforations, it was 53%. Two types of perforation were seen, one occurring in the setting of necrotizing enterocolitis, and the other, a simple perforation in an otherwise normal-appearing bowel. For the latter group, the survival rate was 86%, and, when possible, primary repair was the procedure of choice. Use of aminophylline was greater in the control group. Otherwise, there were no significant differences between the two groups in any of the variables observed. However, when the simple perforations were observed separately, these patients had, on average, received indomethacin at a younger age than the controls (P < .05). The clustering of perforation cases from May through August suggests an infectious agent might be involved.

CONCLUSIONS

Earlier administration of indomethacin correlates with an increased risk of focal perforation. It is unclear, however, whether the risk factor is the drug itself or the earlier need for it. Aminophylline use was somewhat more in the control group, but this is not likely to reflect a protective role for that drug. The possible involvement of an infectious agent should be considered.