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Final prenatal ultrasounds (37 weeks gestational age and 36.2 weeks gestational age, respectively) of patients found to have a fibrinous peel at delivery. Arrows point to distorted bowel
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Several studies in animal models demonstrate that peel formation in gastroschisis is due to the accumulation and activation of intestinal waste products (IWP) in the amniotic fluid. We reviewed our recent experience with gastroschisis and asked the following questions: First, does staining of the bowel and amniotic fluid with IWP correlate with int...
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... ultrasound studies of the 12 infants who underwent prenatal management were reviewed. Matting was defined as the distortion of bowel architecture such that large and small bowel cannot be distinguished. When matting occurs, the walls adjacent to the bowel serosa do not separate on ultrasound manipulation. Four of these 12 infants had a peel at the time of delivery and had demonstrated matting of the bowel on prenatal ultrasound exam ( Fig. 1, Table 2). Furthermore, all four infants had staining of the bowel and amniotic fluid with IWP at birth. Thus, peel formation correlated with both ultrasound matting and staining of the amniotic fluid. In this report, we present data that support the hypothesis that IWP in the amniotic fluid play a role in the formation of intestinal peel in gastroschisis. These preliminary findings provide an important clinical correlate to animal models that demonstrate a potential cause and effect relationship between IWP and peel formation. However, a larger study in which the amniotic fluid of infants with peel is sampled for specific enzymes and their concentrations and activities needs to be undertaken in order to strengthen this hypothesis. We observed that there was some variability of the severity of peel formation at the time of delivery among the infants in the staining group, ranging from very light peel with bowel edema to significant distortion of the bowel architecture. This suggests that the formation of a peel may occur over a period of days to weeks. Several reports have indicated that IWP or meconium may be present in the amniotic fluid as early as the latter half of the second trimester [11, 12]. The accumulation of these products may occur over time if the normal mechanisms for clearance of these products are impaired. If this hypothesis on IWP accumulation is correct, then the variation in the severity of the peel that we observed would be related to the duration of exposure as well as the concentration of the IWP in utero [13]. One must not discount that there may be other mechanisms involved in the formation of intestinal peel. Langer et al. developed a sheep model in which thick- ening of the bowel serosa occurred due to constriction of the mesentery [14]. This was thought to result from lymphatic and venous congestion and may represent either a component of a multifactoral process or a completely separate mechanism of peel formation. The findings of matting and distortion of the intestinal architecture on prenatal ultrasound correlate with the finding of a fibrinous peel at the time of birth and may be a useful indicator of bowel injury. However, this observation needs to be confirmed in other studies with larger numbers of patients. Nevertheless, the identifica- tion of ultrasonic markers for patients at risk for peel formation may help perinatologists and surgeons with the prenatal planning and postnatal management of these patients. Three of the four infants with postoperative complications (including those with major complications) were less than 35 weeks gestational age at delivery. The mothers of these infants received peripartum steroids to promote fetal lung maturity prior to delivery. Addi- tionally, none of the four infants in this group presented with an intestinal peel. Although these numbers are very small and meaningful statistical comparisons cannot be made, they raise the question of whether a lack of intestinal peel combined with immaturity and the anti- inflammatory effects of steroids prevent fixation of the intestine in the setting of malrotation and thus increases the risk of volvulus. We provide evidence that the presence of IWP in the amniotic fluid correlates with the formation of intestinal peel in gastroschisis. Ultrasound findings of distortion and matting of the bowel in utero suggest that peel formation is occurring. These data are consistent with previous studies in animal models and support the hypothesis that IWP are critical in the formation of intestinal ...
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OBJECTIVES AND INTRODUCTION: Gastroschisis is a congenital abdominal wall defect with increasing occurrence worldwide over the past 20-30 years. Our aim was to analyze the morbidity of newborns after gastroschisis closure, with emphasis on metabolic and hydroelectrolyte disturbances in patients at three tertiary university centers.
From January 200...
Citations
... In addition, our finding of a higher prevalence of meconium-stained amniotic fluid in cases of preterm delivery was consistent with current data 25 and further supported the involvement of meconium and intestinal waste products in bowel injury. 26,27 Interestingly, regarding the US markers, although all cases of intra-abdominal bowel dilation were delivered preterm, no association with SLO was observed. Nevertheless, our findings suggest a trend of prematurity due to fetal distress in fetuses with stomach and bladder herniations. ...
Introduction:
The present study aims to investigate the association of spontaneous labor onset with neonatal outcomes in pregnancies with fetal gastroschisis. The secondary goal was to evaluate the association between ultrasound markers and labor onset in pregnancies with fetal gastroschisis.
Material and methods:
A retrospective analysis was performed for 207 pregnancies with fetal gastroschisis followed between 2005 and 2017. Patients were followed according to a strict protocol involving ultrasound scans and routine evaluations of fetal biophysical profile parameters and intra- and extra-abdominal bowel diameters. Labor, delivery and neonatal records were reviewed. The neonatal outcomes were complex gastroschisis, staged surgical closure of the abdominal defect, short bowel syndrome, time on mechanical ventilation, time to full enteral feeding and necrotizing enterocolitis.
Results:
Spontaneous labor onset was associated with complex gastroschisis (30.7% vs. 6.8%, p = 0.002) and short bowel syndrome (13.2% vs. none, p = 0.013) in cases with spontaneous preterm delivery compared to the indicated preterm deliveries. Spontaneous labor onset was associated with a longer time on mechanical ventilation for term and preterm newborns. Associations were not observed between ultrasound markers and spontaneous labor onset.
Conclusion:
Spontaneous labor onset in pregnancies with fetal gastroschisis was associated with adverse neonatal outcomes particularly in those born at preterm gestation. This article is protected by copyright. All rights reserved.
... Meconium staining of amniotic fluid may also be important. One study found that fibrinous peel on the bowel only occurred when meconium staining of the amniotic fluid was present, however the exact etiology of peel formation remains unknown 29 . ...
To compare perinatal and infant surgical outcomes in fetuses with gastroschisis with and without gastric dilation in a single-center cohort.
This was a retrospective study of all singleton pregnancies with a prenatal diagnosis of gastroschisis managed at University of Toronto perinatal centers between January 2001 and February 2010. Digital prenatal ultrasound images were reviewed to determine fetal gastric size within 2 weeks of delivery. Perinatal and surgical outcomes were compared in fetuses with and without gastric dilation including: gestational age at delivery, mode of delivery, indication for Cesarean section, meconium-stained amniotic fluid, birth weight percentile, Apgar scores at 1 and 5 min, umbilical artery pH, time to full enteral feeding, length of hospital stay, bowel atresia or necrosis and need for bowel resection.
Ninety-eight fetuses with prenatally diagnosed gastroschisis managed at our center were included in the study, of which 32 (32.7%) were found to have gastric dilation. Gastric dilation predicted meconium-stained amniotic fluid at delivery (53% vs. 24%; P = 0.017), but no other adverse perinatal outcome. Surgical morbidity rates (bowel atresia, bowel necrosis, perforation diagnosed postnatally, need for bowel resection, total time to full enteral feeding and length of hospital stay) were unaffected by gastric dilation.
In gastroschisis, fetal gastric dilation is associated with meconium-stained amniotic fluid at delivery, but is not predictive of any serious perinatal or postnatal complications. Fetal growth and well-being should be serially evaluated on ultrasound using biophysical and Doppler assessment to decide on the optimal timing and mode of delivery.
... First, gastroschisis is readily diagnosed in utero. Second, increasing evidence indicates that the external surface of the intestines are injured by the accumulation of intestinal waste products in the amniotic fluid [Akgur et al., 1998;Olguner et al., 2000Olguner et al., , 2006Api et al., 2001;Tanyel, 2002;Nichol et al., 2004;Caglar et al., 2007], resulting in an inflammatory peel (Fig. 3). Animal models have demonstrated that the evisceration of the intestine into the amniotic cavity results in shortening of the bowel and delayed maturation of the enteric nervous system [Correia-Pinto et al., 2001;Vannucchi et al., 2003;Midrio et al., 2004]. ...
... A major challenge in human studies has been lack of a systematic method of staging inflammatory peel and measuring its impact on post-natal outcomes. To date, all retrospective studies rely on the qualitative assessment of inflammatory peel by the surgeon [Nichol et al., 2004;Ergun et al., 2005]. Typically, only patients with significant intestinal damage are considered to have peel. ...
Gastroschisis is one of the most challenging congenital anomalies that physicians treat in the first 2 months of life. Over the last 40 years, tremendous progress has been made in the management of this defect. Survival has increased significantly during this period as well. However, gastroschisis still presents the clinician with a unique set of challenges as a result of secondary effects on intestinal development. These challenges or clinical considerations are discussed in this review including a history of the management of the defect, prenatal counseling, prenatal intervention, postnatal and surgical management, complications and long-term outcomes.
Objective:
We compared outcomes of elective late preterm delivery at 34 weeks (ED) with routine obstetric care (RC) in babies with gastroschisis.
Methods:
Between May 2013 and September 2015, all women with a sonographically diagnosed gastroschisis referred to a single tertiary center before 34 weeks gestation were invited to participate in this study. Eligible patients were randomized to ED versus RC. The primary outcome measure was duration on total parenteral nutrition (TPN). Secondary outcomes were time to closure and length of stay. Outcome variables were compared using appropriate statistical methods. Analysis was based on intention-to-treat.
Results:
Eighty-four percent (21/25; 95% CI 63.9-95.5%) of eligible women were randomized; 10 to elective late preterm delivery and 11 to routine obstetric care. The trial was stopped at the first interim analysis after 21 of 86 planned patients were enrolled (24.4%, 95% CI 15.8-34.9%) for both patient safety concerns and for futility. The median gestational age at delivery was 34.3 weeks [34, 36] in the ED group and 36.7 [27, 38] in the RC group. Neonates of women who underwent elective preterm delivery had no difference in the primary outcome of duration on TPN and secondary outcomes of time to closure of gastroschisis and length of stay, but were significantly more likely to experience late-onset sepsis (Duration on TPN: ED 54 [17, 248], RC: 21 [9, 465], P = 0.08; Time to Closure: ED 7 [0, 15], RC 5 [0, 8] days, P = 0.28; Length of Stay: ED 70.5 [22, 137], RC: 31 [19, 186], P = 0.15; Neonatal Sepsis: ED 40%; 95% CI 12.2-73.8%, RC: 0%, P = 0.03) CONCLUSION: This study demonstrates no benefit of elective late preterm delivery of fetuses with gastroschisis when postnatal gastroschisis management is similar to that used in routine care. Rather, the data suggest that elective preterm delivery is detrimental to infants with gastroschisis. This article is protected by copyright. All rights reserved.
Cambridge Core - Obstetrics and Gynecology, Reproductive Medicine - High-Risk Pregnancy - edited by David James
Introduction. The mode of delivery for gravidas with fetuses with GS plays an important role among the factors influencing the results of gastroschisis (GS) treatment. More researchers come to univocal conclusion that elective and early cesarean section has positive impact on elimination (prevention) of GS complications compared to previous experience in natural deliveries in term. However, the impact of the mode of delivery to anatomical features of GS remains still not investigated.
The objective of the research was to determine the impact of the delivery mode on anatomical characteristics of newborn children with GS.
Materials and methods. Retrospective analysis of 100 patients’ case histories was conducted. Infants were born naturally or via C-section during the period from 1987 to 2015. All newborns were divided into 3 clinical groups according to prenatal diagnosis, mode of delivery, transportation, place and term of surgical treatment of GS.
Results. Localization of penetration defect of anterior abdominal wall (AAW) remains constant and typical for GS in every clinical group; therefore the mode of delivery did not have any impact upon the localization of defects in case of this malformation. The size of the penetration defect was significantly smaller in children after C-section than those born via vaginal deliveries. Thus, in Group I (children born via C-section) the defects sizes were 3.15 ± 0.09 cm, while in Groups II and III (after vaginal deliveries) the sizes were 4.17 ± 0.3 cm, p
Until the 1980s, physicians had few options for parents of fetuses with congenital malformations; essentially, these were to terminate the pregnancy or continue and possibly modify the timing and/or method of delivery. Rapid advances in prenatal imaging and diagnosis over the last 20 years, coupled with increased understanding of the natural history of many fetal anomalies, has led to the identification of the fetus as a patient and to the burgeoning field of fetal surgery. An increasing number of selected fetal anomalies are amenable to prenatal intervention (Table 73.1), yet it has been difficult to demonstrate efficacy with regard to improved outcomes. With the exception of myelomeningocele and twin–twin transfusion syndrome, anomalies amenable to fetal repair yield only 2–5 cases per year at the busiest fetal treatment centers. Thus, the dearth of patient volume has dictated that outcome assessment be done over a long time often using historical controls. Also, anomalies in which no prenatal treatment reliably results in fetal death (e.g., lung lesion producing hydrops) cannot be ethically “randomized” for prospective study. Randomized prospective trials have been done for several “high” volume anomalies. To date, there are two completed randomized trials for congenital diaphragmatic hernia, and there are ongoing prospective randomized trials for myelomeningocele and twin–twin transfusion syndrome, each of which is illustrated below. Risks and benefits Assessing risks and benefits in fetal surgery is a complex task. Both the fetus and the mother must be considered.
Although abdominal wall defects have been recognized and described since ancient times, virtually all significant anomalies of abdominal wall development were fatal until the last century. The first substantial advancement in the care of infants with large abdominal wall defects was the development by Gross of a staged technique for the closure of omphaloceles with skin flaps. The resulting ventral hernia defect and lateral displacement of abdominal wall musculature often caused considerable morbidity, but this was acceptable in light of the alternative. The second development that had a major impact on survival was the introduction of temporary coverage by prosthetic materials, allowing gradual reduction of the eviscerated structures and delayed fascial closure. Both of these techniques were applicable to omphaloceles with functional intestinal tracts protected by intact amniotic membranes. Improvements in survival for gastroschisis awaited the advent of techniques for parenteral nutrition to provide metabolic and nutritional support and allow time for the injured intestinal tract to become functional. Currently, survival with an acceptable quality of life is expected for most infants with isolated abdominal wall defects, and mortality is primarily related to associated anomalies. Formation of the normal ventral abdominal wall requires the successful orchestration of many complex events that occur primarily from the fourth to the twelfth week of fetal development. These events include the folding, fusion, growth, and differentiation of embryonic tissues destined to become abdominal wall musculature, umbilicus, and the intestinal tract.
Objective:
To investigate the association between meconium staining and perinatal and neonatal outcomes in pregnancies with gastroschisis.
Methods:
Retrospective analysis of infants with prenatally diagnosed gastroschisis born in two academic medical centers between 2008 and 2013. Neonatal outcomes of deliveries with and without meconium staining were compared. Primary outcome was defined as any of the following: neonatal sepsis, prolonged mechanical ventilation, bowel atresia or death. Secondary outcomes were preterm delivery, preterm-premature rupture of membranes (PPROM) and prolonged hospital length of stay.
Results:
One hundred and eight infants with gastroschisis were included of which 56 (52%) had meconium staining at delivery. Infants with meconium staining had a lower gestational age at delivery (36.3 (±1.4) versus 37.0 (±1.2) weeks, p = 0.007), and a higher rate of PPROM (25% versus 8%, p = 0.03) than infants without meconium. Meconium staining was not significantly associated with the primary composite outcome or with any of its components. After adjustments, meconium staining remained significantly associated with preterm delivery at <36 weeks [odds ratio OR = 4.0, 95% confidence intervals (CI): 1.5-11.4] and PPROM (OR = 3.8, 95%CI: 1.2-14.5).
Conclusions:
Among infants with gastroschisis, meconium staining was associated with prematurity and PPROM. No significant increase in other adverse neonatal outcomes was seen among infants with meconium staining, suggesting a limited prognostic value of this finding.
