Article

Expectant Management Compared With Elective Delivery at 37 Weeks for Gastroschisis

May 2013
Obstetrics and Gynecology 121(5):990-8

May 2013
121(5):990-8

DOI:10.1097/AOG.0b013e31828ec299

Source
PubMed

Authors:

David Baud

Lausanne University Hospital

Andrea Lausman

St. Michael's Hospital

P. G. R. Seaward

University of Toronto

Show all 9 authorsHide

: To estimate obstetric and neonatal outcomes after induction of labor at 37 weeks of gestation compared with expectant management in pregnancies complicated by fetal gastroschisis. : The management of 296 pregnancies involving fetal gastroschisis (1980-2011) was reviewed from a single perinatal center. Ultrasound surveillance and nonstress testing were performed every 2 weeks from 30 weeks of gestation, weekly from 34 weeks of gestation, and twice weekly after 35 weeks of gestation until delivery. Labor was induced if fetal well-being testing was abnormal and, since 1994, labor was routinely induced at 37 weeks of gestation. : Of 153 pregnancies reaching 37 weeks of gestation, labor was induced in 77 (26%) and 76 (25.7%) were allowed to labor spontaneously. There were no significant differences in mean maternal age (22 years in both), parity (56% compared with 66% nulliparous), presence of other fetal anomalies (12% compared with 9%), cesarean delivery rate (20% in both), 5-minute Apgar score less than 7 (10% compared with 12%), meconium at birth (36% compared with 49%), or respiratory distress syndrome (16% compared with 7%) between the induced and expectantly managed groups. However, neonatal sepsis (25% compared with 42%; P=.02) and a composite outcome of neonatal death and bowel damage (necrosis, atresia, perforation, adhesion; 8% compared with 21%; P=.02) were more common in expectantly managed pregnancies. Moreover, time to oral feeds (-3.4 days), time on total parenteral nutrition (-6.2 days), and hospital stay (-6.7 days) were reduced when labor was induced. : In fetuses with gastroschisis, induction of labor at 37 weeks of gestation was associated with reduced risks of sepsis, bowel damage, and neonatal death compared with pregnancies managed expectantly beyond 37 weeks of gestation. : II.

Preterm versus Term Delivery in Antenatally Diagnosed Gastroschisis: A Systematic Review and Meta-Analysis

Article

Apr 2022

Objective To review the evidence regarding gestational age at birth, length of stay, sepsis incidence, days on mechanical ventilation, and mortality between preterm and term deliveries in pregnancies complicated by gastroschisis. Data Sources We conducted database searches PubMed, CENTRAL, EMBASE, WHO ICTRP, and clinicaltrials.gov without language restrictions through August 16, 2021. References of all relevant articles were reviewed. Study Eligibility Criteria Randomized control trials, non-randomized control trials, and observational studies were evaluated comparing length of stay, sepsis, days on mechanical ventilation, and mortality with either elective preterm delivery versus expectant management (Group 1) or preterm gestational age versus term gestational age (Group 2). Study Appraisal and Synthesis Methods Two researchers independently selected studies and evaluated risk of bias with Risk of Bias 2 tool for randomized control trials and the Newcastle-Ottawa Scale for cohort studies. Mean differences and odds ratios were calculated using a random effects model for inclusion and methodological quality. The primary outcome was length of stay. Secondary outcomes were incidence of sepsis, mortality, days on mechanical ventilation, and gestational age. Results Thirty studies with a total of 7,409 patients were included in the systematic review, of which 25 were included in the analysis. Group 1 studies found no difference in length of stay or mortality and a trend toward fewer days on mechanical ventilation (MD -0.40, 95% CI -0.89-0.10, p=0.12, I²=35%). Subgroup analysis excluding premature delivery demonstrated lower sepsis incidence in elective preterm delivery (OR 0.46, 95% CI 0.25-0.84, p=0.01, I²=0%). Group 2 studies found increased length of stay (MD 15.44, 95% CI 8.44-21.83, p<0.00001, I²=94%), sepsis (OR 1.69, 95% CI 1.15-2.50, p=0.008, I²=51%), days on mechanical ventilation (MD 1.38, 95% CI 0.10-2.66, p=0.03, I²=66%), and mortality (OR 2.97, 95% CI 1.59-5.55, p=0.0007, I²=0%). Gestational age was significantly lower in Group 2 studies compared with Group 1 studies. Conclusion Data continue to be conflicting, but subgroup analysis suggests a possible reduction in sepsis incidence and mean days on mechanical ventilation with elective early term delivery.

Gastroschisis: a systematic review of diagnosis, prognosis and treatment

Article

Apr 2021

Objectives: The present systematic review aims to investigate the diagnosis, prognosis, delivery assistance, pregnancy results and postnatal management in gastroschisis. Study design: The following data sources were evaluated: The CINAHL, Embase and MEDLINE/ PubMed databases were searched, observational and intervention studies published over the past 20 years. The quality of the studies was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Results: A total of 3770 infants diagnosed with gastroschisis were included (44 studies); 1534 fetuses were classified as simple gastroschisis and 288 as complex gastroschisis. Intrauterine fetal demise occurred in 0.47% and elective termination occurred in 0.13%. Preterm delivery occurred in 23.23% and intrauterine growth restriction in 4.43%. Cesarean section delivery was performed in 54.6%. Neonatal survival was 91.29%. The main neonatal complications were: sepsis (11.78%), necrotizing enterocolitis (2.33%), short bowel syndrome (1.37%), bowel obstruction (0.79%), and volvulus (0.23%). Immediate surgical repair was performed in 80.1% with primary closure in 69%. The average to oral feeding was 33 (range: 11–124.5) days. Average hospital duration was 38 days and 89 days in neonates with simple and complex grastroschisis, respectively. Conclusions: The present systematic review provides scientific data for counseling families with fetal gastroschisis.

Outcomes in infants with prenatally diagnosed gastroschisis and planned preterm delivery

Article

Full-text available

Nov 2015
PEDIATR SURG INT

Background The timing and mode of delivery of pregnancies with prenatally diagnosed gastroschisis remains controversial. Aim To evaluate the outcome of patients with gastroschisis managed during two time periods: 2006–2009 and 2010–2014, with planned elective cesarean delivery at 37 versus 35 gestational weeks (gw). A secondary aim was to analyze the outcome in relation to the gestational age at birth. Material and methods Retrospective review of all cases with gastroschisis managed at our institution between 2006 and 2014. Results Fifty-two patients were identified, 24 during the initial period, and 28 during the second. There were a significantly higher number of emergency cesarean deliveries in the first period. There were no differences between groups with regard to the use of preformed silo, need of parenteral nutrition or length of hospital stay. When analyzing the outcome in relation to the gw the patients actually were born, we observed that patients delivered between 35 and 36.9 gw were primary closed in 88.5 % of cases, with shorter time on mechanical ventilation, parenteral nutrition and hospital stay. Conclusion Planned caesarian section at 35 completed gestational weeks for fetuses with prenatally diagnosed gastroschisis is safe. We observe the best outcome for patients born between 35 and 36.9 gw.

Current practice for gastroschisis prenatal surveillance among society for maternal fetal medicine (SMFM) members

Article

Full-text available

Dec 2022

Abdulraouf Lamoshi

Background Gastroschisis is an abdominal wall defect with potential devastating outcomes, including short bowel syndrome (SBS). The objective of this study is to define current practices in prenatal gastroschisis surveillance. Methods An online survey was circulated to the Society for Maternal Fetal Medicine (SMFM) providers. Questions focused on timing, type, and frequency of surveillance, proposed interventions, and the impact of gastroschisis defect diameter on plan of care. Results Responses were obtained from 150/1104 (14%) SMFM providers. The majority of respondents worked in practices in an academic setting (61%) and more than half (58%) had been in maternal fetal medicine (MFM) practice for > 10 years. Antenatal testing began at 32 weeks for 78% of MFM providers. Surveillance was unanimously uniformly performed with ultrasound. About 40% of the providers would consider all abnormalities in the measured parameters to change their surveillance frequency. In non-complicated gastroschisis, 44% of the providers would recommend delivery at 37 weeks of gestational age, with the vast majority of them (96%) recommending vaginal delivery. Among the 23% who expressed their thoughts, 70% agreed that a smaller defect size correlated with the higher risk for development of SBS. Nevertheless, only 2% declared an absolute cutoff point (< 8 mm–3 cm) at which they would recommend delivery. Only one-fifth of the participants (21%) noted that the abdominal wall defect size has an impact on development of SBS. A higher percentage of SMFM providers (89%) with ≤ 10 years of experience started the antenatal testing at week 32 weeks compared to 66% of senior providers. Senior providers were more inclined (50%) to induce labor at 37 weeks compared to SMFM providers with > 10 years of experience (38%). Conclusions Gastroschisis management does not differ dramatically among SMFM providers, though noticeable differences in surveillance and timing of induction were identified based on years of experience as providers. The impact of gastroschisis defect dimensions on development of SBS may be under appreciated.

When ultrasonography reveals a fetal abdominal wall defect

Article

Jan 2021

Although these fetal defects are rare, be alert to their potential presence when early ultrasonography indicates structural abnormalities. Here, surveillance, planning, and appropriate patient counseling are reviewed.

Fetal Abdominal Wall Defects

Chapter

Full-text available

May 2018

Management and Outcome Challenges in Newborns with Gastroschisis: A 6-year retrospective French study

Article

Nov 2016

Objective: to identify the gestational age (GA) at which risk of mortality and severe outcome was minimized comparing preterm delivery and expectant management. Methods: Retrospective study performed between 2009 to 2014 of newborns with gastroschisis in three large French level III neonatal intensive care units. Each department followed two distinct strategies: elective delivery at 35 weeks GA and, a delayed approach. Results: We included 69 gastroschisis cases. The lengths of stay lasting more than 60 days was significantly greater in the planned delivery group than in the expectant approach group (18/30 (60%) vs. 8/39 (20.5%), p = 0.001). Gastroschisis cases receiving antenatal corticoids during the last two weeks of gestation required significantly less surgeries during their initial stay (p = 0.003) as well as shorter parenteral feedings (p = 0.002). A multivariate logistic regression showed that a GA of less than 36 weeks GA was is a pejorative factor for a stay above 60 days, regardless of whether it was a simple or complex gastroschisis, (OR= 3.8; p = 0.021). A complex gastroschisis was a risk factor for significantly longer parenteral feedings, regardless of the center where patient is treated (Beta=-0.3, p = 0.035). Conclusion: Future research should focus on decisions about delivery timing by incorporating risk of neonatal morbidity.

Clinical Research Factors Influencing the Survival of Patients with Gastroschisis in A Lower-Middle Income Country: A Retrospective Observational Study

Article

Full-text available

Jan 2024

Background: Survival rate of gastroschisis has improved worldwide due to advancements in antenatal diagnosis, perinatal care and neonatal intensive care. This is in stark contrast with the persistently poor outcomes observed in low and middle-income countries. Aim of this study is to identify factors affecting survival in a resource constraint center, where intensive neonatal care and parenteral nutrition could not be provided.

Improved Mortality of Patients with Gastroschisis: A Historical Literature Review of Advances in Surgery and Critical Care from 1960–2020

Article

Full-text available

Sep 2022

The improved survival of gastroschisis patients is a notable pediatric success story. Over the past 60 years, gastroschisis evolved from uniformly fatal to a treatable condition with over 95% survival. We explored the historical effect of four specific clinical innovations—mechanical ventilation, preformed silos, parenteral nutrition, and pulmonary surfactant—that contributed to mortality decline among gastroschisis infants. A literature review was performed to extract mortality rates from six decades of contemporary literature from 1960 to 2020. A total of 2417 publications were screened, and 162 published studies (98,090 patients with gastroschisis) were included. Mortality decreased over time and has largely been <10% since 1993. Mechanical ventilation was introduced in 1965, preformed silo implementation in 1967, parenteral nutrition in 1968, and pulmonary surfactant therapy in 1980. Gastroschisis infants now carry a mortality rate of <5% as a result of these interventions. Other factors, such as timing of delivery, complex gastroschisis, and management in low- and middle-income countries were also explored in relation to gastroschisis mortality. Overall, improved gastroschisis outcomes serve as an illustration of the benefits of clinical advances and multidisciplinary care, leading to a drastic decline in infant mortality among these patients.

A narrative review about challenges in periand postnatal management of gastroschisis

Article

Full-text available

Aug 2021

Gastroschisis is a malformation of the closure of the anterior abdominal wall which has had a growing incidence in recent years. It is a borderline pathology between several specialties such as: obstetrics, neonatology, pediatric surgery, family medicine and requires many resources. In general, the chance of survival of newborns with gastroschisis is high. However, complex cases with complications are more likely to have an unfavorable prognosis. The therapeutic plan should start from the intra-embryonic period, from the time of the ultrasound diagnosis and it should extend over a long period of time, which can vary depending on the case, and on the surgical options. When it comes to the management of the cases, there is no valid protocol for all the cases, and there is a great variability starting with the choice of birth time, birth pathway, the option of reintegrating the intestinal loops and closing the abdominal defect. Because of this, the cases of gastroschisis represent a challenge for modern medicine, when also taking into account the fact that the etiopathogenesis of this malformation is not clearly established and that there is a large variety of therapeutic options.

Abdominal Wall Defects—Current Treatments

Article

Full-text available

Feb 2021

Gastroschisis and omphalocele reflect the two most common abdominal wall defects in newborns. First postnatal care consists of defect coverage, avoidance of fluid and heat loss, fluid administration and gastric decompression. Definitive treatment is achieved by defect reduction and abdominal wall closure. Different techniques and timings are used depending on type and size of defect, the abdominal domain and comorbidities of the child. The present review aims to provide an overview of current treatments.

Outcome of management of gastroschisis: comparison of improvised surgical silo and extended right hemicolectomy

Article

Full-text available

Dec 2020

Background Gastroschisis is onea of the major abdominal wall defects encountered commonly in pediatric surgery. Whereas complete reduction and abdominal closure is achieved easily sometimes, a daunting situation arises when the eviscerated bowel loops and other viscera cannot be returned immediately into the abdominal cavity. This situation is a major contributor to the outcome of the treatment of gastroschisis in our region. In our efforts to improve our outcome, we have adopted the technique of extended right hemicolectomy for cases where complete reduction and primary abdominal wall closure is otherwise not possible. This study compared the management outcome of gastroschisis using our improvised silo, and performing an extended right hemicolectomy. Results Thirty-nine cases were analyzed. Simple closure could not be achieved in 28 cases. In the absence of standard silos, improvised ones were constructed from the amniotic membrane (3 cases), urine bag (4 cases), and latex gloves (9 cases) giving a total of 16 cases managed with silos. Extended right hemicolectomy was performed in 12 cases. Conclusions Given the peculiarities of circumstances in our region regarding human and material resources in the care of gastroschisis patients, an extended right hemicolectomy, to make it possible to close the abdomen primarily in gastroschisis is a more viable option than the use of improvised silo. Trial registration This trial was approved by the Ethical Committee of the University of Port Harcourt Teaching Hospital, Nigeria. Reference Number: UPTH/ADM/90/S.II/VOL XI/835. Registered 3 May 2013.

Prenatal Diagnosis dan Penatalaksanaan Gastroskisis

Article

Full-text available

Sep 2019

William Alexander Setiawan

Gastroskisis merupakan defek kongenital yang terjadi pada dinding abdomen janin. Kejadian yang dilaporkan di seluruh dunia berkisar antara 4-5 per 10.000 kelahiran hidup. Mortalitas pada bayi yang lahir dengan gastroschisis telah menurun selama bertahun-tahun tetapi morbiditas masih tetap tinggi. Diperlukan prenatal diagnosis yang optimal agar proses melahirkan bisa dipersiapkan sebaik mungkin. Pada prenatal diagnosis dilakukan penilaian defek kongenital lainnya agar hasil klinis lebih baik dengan manajemen lebih awal, selain itu dilakukan juga penilaian untuk menentukan adanya kelainan kromosom atau tidak. Apabila kelainan tersebut bersifat isolated, maka hasil klinis akan lebih baik dibandingkan gastroschisis dengan kelainan kromosom. Metode persalinan dan waktu persalinan yang direkomendasikan yaitu pada usia kehamilan 37 minggu dengan metode sectio caesarea. Manajemen neonatal meliputi persalinan di fasilitas kesehatan tersier dan manajemen bedah paska kelahiran yaitu penutupan bedah primer, penutupan bertahap dengan silo, atau penutupan umbilikal tanpa jahitan. Prenatal Diagnosis and Management of Gastroschisis Abstract Gastroskisis is a congenital defect that occurs in the fetal abdominal wall. Events reported throughout the world range from 4-5 per 10,000 live births. Mortality in infants born with Gastroskisis has declined over the years but morbidity is still high. An optimal prenatal diagnosis is needed so that the labor can be prepared as well as possible. Prenatal diagnosis is done by assessing other congenital defects so that clinical results are better with earlier management, in addition assessment is also done to determine whether there is a chromosome abnormality or not. If the abnormality is isolated, the clinical results will be better than Gastroskisis with chromosomal abnormalities. The recommended method of delivery and labor time is 37 weeks gestational age with the sectio caesarea method. Neonatal management includes delivery in tertiary health facilities and management of postnatal surgery namely primary surgical closure, staged reduction with silo and sutureless umbilical closure. Key words : Congenital Defect, Gastroskisis, Prenatal Diagnosis

Factors that Influence Longitudinal Growth from Birth to 18 Months of Age in Infants with Gastroschisis

Article

Jul 2019

Objective To investigate factors that influence growth in infants with gastroschisis. Study Design Growth parameters at birth, discharge, 6, 12, and 18 months of age were collected from 42 infants with gastroschisis. Results The mean z-scores for weight, length, and head circumference were below normal at birth and decreased between birth and discharge. Lower gestational age correlated with a worsening change in weight z-score from birth to discharge (rho 0.38, p = 0.01), but not with the change in weight z-score from discharge to 18 months (rho 0.04, p = 0.81). There was no correlation between the day of life when the enteral feeds were started and the change in weight z-score from birth to discharge (rho 0.12, p = 0.44) or discharge to 18 months (rho −0.15, p = 0.41). Conclusion Our study demonstrates that infants with gastroschisis experience a significant decline in weight z-score between birth and discharge, and start to catch up on all growth parameters after discharge. Prematurity in gastroschisis infants is associated with a greater risk for weight loss during this time. This information emphasizes the importance of minimizing weight loss prior to discharge in premature infants with gastroschisis and highlights the need for optimal management strategies for these infants.

Gastroschisis: A review of practice

Article

Dec 2017

Gastroschisis is an abdominal wall defect in the fetus, affecting as many as 1 in 2000 pregnancies. This is a complex medical condition that is growing in prevalence worldwide, and one to which midwives will inevitably be exposed. There is a lack of consensus in the literature as to the cause of gastroschisis and for clear evidence-based treatment regarding indication and timing of birth. While it is agreed that specialist multidisciplinary collaboration is needed from pre-conception, through antenatal surveillance, and into labour, birth and postnatal care, the research is medically led, with no description of a midwifery role. In acknowledging that gastroschisis is a complex medical issue, specific medical and surgical interventions are not examined, but instead a midwifery plan of care within the multidisciplinary approach is derived from the available literature.

An unusual cause of delayed full enteral feeding and prolonged hospital stay in a newborn with gastroschisis: Congenital Hypothyroidism

Article

Full-text available

May 2016

Sevgi Büyükbeşe Sarsu

Outcomes of Infants with Abdominal Wall Defects over 18Years

Article

Jun 2016
J PEDIATR SURG

Infants with abdominal wall defects (AWD) are at risk of poor outcomes including prolonged hospitalization, infections and mortality. Our objective was to describe and compare the outcomes of infants admitted with gastroschisis and omphalocele over 18 years. Population-based study of clinical data and outcomes of live-born infants with AWD admitted to all tertiary-level neonatal intensive care units in New South Wales and Australian. Capital Territory from 1992 to 2009. There were 502 infants with AWD – 336 gastroschisis, 166 omphalocele. Infants with gastroschisis required a longer duration of total parenteral nutrition (19 vs 4 days, p < 0.05), longer hospitalization (28 vs 15 days, p < 0.05) and had a higher rate of systemic infection [23.5% vs 13.3%, OR 1.77(1.15–2.74), p < 0.05] compared to infants with omphalocele. Overall, omphalocele infants had higher mortality rate compared to gastroschisis infants [OR 2.77(1.53, 5.04), p < 0.05]. Gastroschisis mortality rates increased from epoch 1 to epoch 3 (4.2% to 8.8%). Compared to infants with omphalocele, infants with gastroschisis required significantly longer hospitalization and parenteral nutrition with higher rates of infection. Infants with omphalocele had higher overall mortality rates. However, there has been an increase in the gastroschisis mortality rates but the cause for this is unclear.

Gastroschisis: Epidemiology and Mode of Delivery, 2005-2013

Article

Mar 2016

Background: Gastroschisis is a severe congenital anomaly the etiology of which is unknown. Research evidence supports attempted vaginal delivery for pregnancies complicated by gastroschisis in the absence of obstetric indications for cesarean delivery. Objective: The objectives of the study evaluating pregnancies complicated by gastroschisis were to: (i) determine the proportion of women undergoing planned cesarean versus attempted vaginal delivery; and (ii) provide up-to-date epidemiology on risk factors associated with this anomaly. Study design: This population-based study of United States natality records from 2005-2013 evaluated pregnancies complicated by gastroschisis. Women were classified based on whether they attempted vaginal delivery or underwent a planned cesarean (n=24,836,777). Obstetrical, medical, and demographic characteristics were evaluated. Multivariable log-linear regression models were developed to determine factors associated with mode of delivery. Factors associated with the occurrence of the anomaly were also evaluated in log-linear models. Results: Of 5,985 pregnancies with gastroschisis, 63.5% (n=3,800) attempted vaginal delivery and 36.5% (n=2,185) underwent planned cesarean delivery. The rate of attempted vaginal delivery increased from 59.7% in 2005 to 68.8% in 2013. Earlier gestational age and Hispanic ethnicity were associated with lower rates of attempted vaginal delivery. Factors associated with the occurrence of gastroschisis included young age, smoking, high educational attainment, and being married. Protective factors included chronic hypertension, black race, and obesity. The incidence of gastroschisis was 3.1 per 10,000 pregnancies and did not increase during the study period. Conclusion: Attempted vaginal delivery is becoming increasingly prevalent for women with a pregnancy complicated by gastroschisis. Recommendations from research literature findings may be diffusing into clinical practice. A significant proportion of women with this anomaly still deliver by planned cesarean suggesting further reduction of surgical delivery for this anomaly is possible.

Effect of Gestational Age at Birth on Neonatal Outcomes in Gastroschisis

Article

Full-text available

Feb 2016

Introduction: Induced birth of fetuses with gastroschisis from 34weeks gestational age (GA) has been proposed to reduce bowel damage. We aimed to determine the effect of birth timing on time to full enteral feeds (ENT), length of hospital stay (LOS), and sepsis. Methods: A retrospective analysis (2000-2014) of gastroschisis born at ≥34weeks GA was performed. Associations between birth timing and outcomes were analyzed by Mann-Whitney test, Cox regression, and Fisher's exact test. Results: 217 patients were analyzed. Although there was no difference in ENT between those born at 34-36+6weeks GA (median 28 range [6-639] days) compared with ≥37weeks GA (27 [8-349] days) when analyzed by Mann-Whitney test (p=0.5), Cox regression analysis revealed that lower birth GA significantly prolonged ENT (p=0.001). LOS was significantly longer in those born at 34-36+6weeks GA (42 [8-346] days) compared with ≥37weeks GA 34 [11-349] days by both Mann-Whitney (p=0.02) and Cox regression analysis (p<0.0005). Incidence of sepsis was higher in infants born at 34-36+6weeks (32%) vs. infants born at ≥37weeks (17%; p=0.02). Conclusions: Early birth of fetuses with gastroschisis was associated with delay in reaching full enteral feeds, prolonged hospitalization, and a higher incidence of sepsis.

Predicting Perinatal Outcome from Prenatal Ultrasound Characteristics in Pregnancies Complicated by Gastroschisis

Article

Dec 2015
FETAL DIAGN THER

Introduction: The objective of the study was to establish the predictive value of prenatal ultrasound markers for complex gastroschisis (GS) in the first 10 days of life. Material and methods: In this retrospective cohort study over 11 years (2000-2011) of 117 GS cases, the following prenatal ultrasound signs were analyzed at the last second- and third-trimester ultrasounds: intrauterine growth restriction, intra-abdominal bowel dilatation (IABD) adjusted for gestational age, extra-abdominal bowel dilatation (EABD) ≥25 mm, stomach dilatation, stomach herniation, perturbed mesenteric circulation, absence of bowel lumen and echogenic dilated bowel loops (EDBL). Results: Among 114 live births, 16 newborns had complex GS (14.0%). Death was seen in 16 cases (13.7%): 3 intrauterine fetal deaths, 9 complex GS and 4 simple GS. Second-trimester markers had limited predictive value. Third-trimester IABD, EABD, EDBL, absence of intestinal lumen and perturbed mesenteric circulation were statistically associated with complex GS and death. IABD was able to predict complex GS with a sensitivity of 50%, a specificity of 91%, a positive predictive value of 47% and a negative predictive value of 92%. Discussion: Third-trimester IABD adjusted for gestational age appears to be the prenatal ultrasound marker most strongly associated with adverse outcome in GS.

Predictive factors at birth of the severity of gastroschisis

Article

Full-text available

Nov 2015

Anthony de Buys Roessingh

AIM: To establish children born with gastroschisis (GS). METHODS: We performed a retrospective study covering the period from January 2000 to December 2007. The following variables were analyzed for each child: Weight, sex, apgar, perforations, atresia, volvulus, bowel lenght, subjective description of perivisceritis, duration of parenteral nutrition, first nasogastric milk feeding, total milk feeding, necrotizing enterocolitis, average period of hospitalization and mortality. For statistical analysis, descriptive data are reported as mean ± standard deviation and median (range). The non parametric test of Mann-Whitney was used. The threshold for statistical significance was P < 0.05 (Two-Tailed). RESULTS: Sixty-eight cases of GS were studied. We found nine cases of perforations, eight of volvulus, 12 of atresia and 49 children with subjective description of perivisceritis (72%). The mortality rate was 12% (eight deaths). Average duration of total parenteral nutrition was 56.7 d (8-950; median: 22), with five cases of necrotizing enterocolitis. Average length of hospitalization for 60 of our patients was 54.7 d (2-370; median: 25.5). The presence of intestinal atresia was the only factor correlated with prolonged parenteral nutrition, delayed total oral milk feeding and longer hospitalization. CONCLUSION: In our study, intestinal atresia was our predictive factor of the severity of GS.

Timing of induction of labor

Article

Sep 2015

Early Closure of Gastroschisis After Silo Placement Correlates with Earlier Enteral Feeding

Article

Full-text available

Jul 2015

Gastroschisis is a congenital anomaly affecting 2.3-4.4/10,000 births. Previous studies show initiation of early enteral feeds predicts improved outcomes. We hypothesize that earlier definitive closure after silo placement; can lead to earlier enteral feed initiation. Design/ Setting/ Duration: Retrospective review of patients with gastroschisis from 2005 and 2014 at a single institution. The data, including ethnicity, gestational age, birth weight, time to definitive closure, and time of first and full feeds, were analyzed using both Spearman's rho and the Kruskal-Wallis rank sum test where appropriate; a p value less than 0.05 was considered significant. Forty-three patients (24 males, 19 females) born with gastroschisis were identified. Overall survival rate was 88% (38/43). Forty of the 43 patients had a silo placed prior to definitive closure. Median days to closure were 6 (0 to 85) days. First feeds on average began on day of life (DOL) 17, and full feeds on DOL 25. Earlier closure of gastroschisis correlated with early initiation of feeds (p=0.0001) and shorter time to full feeds (p=0.018), closure by DOL4 showed a trend toward earlier feeding (p=0.13). Earlier closure of gastroschisis after silo placement was associated with earlier feed initiation and shorter time to full feeds.

Primary Closure in the Management of Gastroschisis

Article

Full-text available

Jan 2024

Optimal timing of delivery for growth restricted fetuses with gastroschisis: A decision analysis

Article

Oct 2023

Objective Our objective was to determine the optimal timing of delivery of growth restricted fetuses with gastroschisis in the setting of normal umbilical artery (UA) Dopplers. Methods We designed a decision analytic model using TreeAge software for a hypothetical cohort of 2000 fetuses with isolated gastroschisis, fetal growth restriction (FGR), and normal UA Dopplers across 34–39 weeks of gestation. This model accounted for costs and quality adjusted life years (QALYs) for the pregnant individual and the neonate. Model outcomes included stillbirth, respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), short gut syndrome (SGS), neonatal sepsis, neonatal death, and neurodevelopmental disability (NDD). Results We found 38 weeks to be the optimal timing of delivery for minimizing overall perinatal mortality and leading to the highest total QALYs. Compared to 37 weeks, delivery at 38 weeks resulted in 367.98 more QALYs, 2.22 more cases of stillbirth, 2.41 fewer cases of RDS, 0.02 fewer cases of NEC, 1.65 fewer cases of IVH, 0.5 fewer cases of SGS, 2.04 fewer cases of sepsis, 11.8 fewer neonatal deaths and 3.37 fewer cases of NDD. However, 39 weeks were the most cost‐effective strategy with a savings of $1,053,471 compared to 38 weeks. Monte Carlo analysis demonstrated that 38 weeks was the optimal gestational age for delivery 51.70% of the time, 39 weeks were optimal 47.40% of the time, and 37 weeks was optimal 0.90% of the time. Conclusion Taking into consideration a range of adverse perinatal outcomes and cost effectiveness, 38–39 weeks gestation is ideal for the delivery of fetuses with gastroschisis, FGR, and normal UA Dopplers. However, there are unique details to consider for each case, and the timing of delivery should be individualized using shared multidisciplinary decision making.

Surgical management of gastroschisis with the use of primary and staged closure based on the department's 20-year experience

Article

Jan 2023

Abstractbackground: Gastroschisis is a common developmental anomaly of the abdominal front wall. The aim of surgical management is to restore the integrity of the abdominal wall and to insert the bowel into the abdominal cavity with the use of the primary or staged closure technique.The objective of this paper is to analyze our 20-year experience with surgical treatment of gastroschisis with primary and staged closure, to compare the postoperative course for the said techniques as well as to identify factors influencing the course and early results of treatment. Methods: The research materials consist of a retrospective analysis of medical history of patients treated at the Pediatric Surgery Clinic in Poznan over 20 years period from 2000 to 2019. 59 patients were operated on: 30 girls and 29 boys. Results: Surgical treatment was performed in all the cases. Primary closure was performed in 32% of the cases, whereas staged silo closure was performed in 68% of the cases. Postoperative analgosedation was used for 6 days on average after primary closures, and 13 days on average after staged closures. Generalized bacterial infection was present in 21% of patients treated with primary closures and 37% for staged closures. Infants treated with staged closure began enteral feeding considerably later (day 22) than those treated with primary closure (day 12). Conclusions: It is not possible to indicate clearly which surgical technique is superior to the other based on the results obtained. When choosing the treatment method, the patient's clinical condition, associated anomalies, and the medical team's experience must be taken into consideration.

Elective Delivery versus Expectant Management for Gastroschisis: A Systematic Review and Meta-Analysis

Article

Jul 2022

Introduction: The optimal timing of delivery for pregnancies complicated by foetal gastroschisis remains controversial. Therefore, the aim of this study is to find whether elective or expectant delivery is associated with improved neonatal outcome. Materials and methods: MEDLINE and Embase databases were searched for studies up to 2021 that reported timing of delivery for foetal gastroschisis. A systematic review and meta-analysis were then performed in group 1: moderately preterm (Gestational age, [GA] 34-35 weeks) elective delivery versus expectant management after GA 34-35 weeks; and group 2: near-term (GA 36-37 weeks) elective delivery versus expectant management after GA 36-37 weeks. The following clinical outcomes were evaluated: length of stay (LOS), total parenteral nutrition (TPN) days, bowel morbidity (atresia, perforation, and volvulus), sepsis, time of first feeding, short gut syndrome and respirator days, and mortality. Results: Two randomised controlled trails (RCT)s and eight retrospective cohort studies were included, comprising of 629 participants. Moderately preterm elective delivery failed to improve clinical outcomes. However, near-term elective delivery significantly reduced bowel morbidity (7.4% vs 15.4%, RR=0.37; CI 0.18, 0.74; p=0.005; I2=0%) and TPN days (MD=-13.44 days; CI -26.68, -0.20; p=0.05; I2=45%) compared to expectant delivery. The mean LOS was 39.2 days after near-term delivery and 48.7 days in the expectant group (p=0.06). Conclusions: Based on the data analysed, near-term elective delivery (GA 36-37 weeks) appears to be the optimal timing for delivery of pregnancies complicated by foetal gastroschisis as it is associated with less bowel morbidity and shorter TPN days. However, more RCTs are necessary to better validate these findings. .

Can fetal MRI aid prognosis in gastroschisis: a multicenter study

Article

Feb 2022

Objective: To assess the contribution and impact of fetal magnetic resonance imaging (MRI) in managing fetal gastroschisis. Methods: We conducted an observational retrospective study of gastroschisis patients at three fetal medicine centers from 2008 to 2019. The primary endpoint was the number of cases in which the MRI provided relevant information related to gastroschisis. Results: A total of 189 patients were included, and our study group included 38 patients who underwent MRI. For the eight patients with suspected gastroschisis, MRI confirmed the diagnosis. In six cases, it provided additional relevant information (spiral turn, intestine ischemia, and bowel size discrepancy). For the 17 patients with ultrasound signs of additional gastrointestinal anomalies, MRI detected one case of unidentified complex gastroschisis on sonography. For the 13 patients undergoing routine MRI, no significant information was obtained. One termination of pregnancy and one fetoscopy were performed a few days after the MRI results. There was no subsequent follow-up or additional bowel complications to support management. Conclusion: Although MRI did not change the management of pregnancies complicated by fetal gastroschisis, patients presenting with fetal gastroschisis with intraabdominal bowel dilatation could benefit from MRI to allow for more precise prenatal counseling to predict postnatal intestinal complications before birth.

Outcome and management in neonates with gastroschisis in the third millennium—a single-centre observational study

Article

Full-text available

Jun 2022
Eur J Pediatr

Gastroschisis is one of the most common congenital malformations in paediatric surgery. However, there is no consensus regarding the optimal management. The aims of this study were to investigate the management and outcome and to identify predictors of outcome in gastroschisis. A retrospective observational study of neonates with gastroschisis born between 1999 and 2020 was undertaken. Data was extracted from the medical records and Cox regression analysis was used to identify predictors of outcome measured by length of hospital stay (LOS) and duration of parenteral nutrition (PN). In total, 114 patients were included. Caesarean section was performed in 105 (92.1%) at a median gestational age (GA) of 36 weeks (range 29–38) whereof (46) 43.8% were urgent. Primary closure was achieved in 82% of the neonates. Overall survival was 98.2%. One of the deaths was caused by abdominal compartment syndrome and one patient with intestinal failure–associated liver disease died from sepsis. None of the deceased patients was born after 2005. Median time on mechanical ventilation was 22 h. Low GA, staged closure, intestinal atresia, and sepsis were independent predictors of longer LOS and duration on PN. In addition, male sex was an independent predictor of longer LOS. Conclusion : Management of gastroschisis according to our protocol was successful with a high survival rate, no deaths in neonates born after 2005, and favourable results in LOS, duration on PN, and time on mechanical ventilation compared to other reports. Multicentre registry with long-term follow-up is required to establish the best management of gastroschisis. What is Known: • Gastroschisis is one of the most common congenital malformations in paediatric surgery with increasing incidence. • There is no consensus among clinicians regarding the optimal management of gastroschisis. What is New: • Although primary closure was achieved in 82% of the patients, mortality rate was very low (1.8%) with no deaths in neonates born after 2005 following the introduction of measurement of intraabdominal pressure at closure. • Low gestational age, staged closure, intestinal atresia, sepsis, and male sex were independent predictors of longer length of hospital stay.

Surgical Management of Gastroschisis With the Use of Primary and Staged Closure on the Basis of the Department's 20-Year Experience

Preprint

Full-text available

Jun 2021

BACKGROUND: Gastroschisis belongs to common developmental anomalies. The aim of surgical management is to restore the integrity of the abdominal wall and to insert the bowel into the abdominal cavity with the use of the primary or staged closure technique. The objective of this paper is to analyze our 20-year experience with surgical treatment of gastroschisis with primary and staged closure, to compare the postoperative course for the said techniques as well as to identify factors influencing the course and early results of treatment. METHODS: The research materials comprise of a retrospective analysis of medical history of patients treated at the Surgery Clinic in Poznan in the years 2000-2019. 59 patients were operated on: 30 girls and 29 boys. Surgical treatment was performed with the use of primary closure in 33% of the cases, whereas the staged silo closure was performed in 67% of the cases. RESULTS: Postoperative analgosedation was used for 6 days on average after primary closures, and for 13 days on average after staged closures. Incidence frequency of generalized bacterial infection was 21% for primary closures and 37% for staged closures. Infants treated with staged closure began enteral feeding considerably later (day 22) than those treated with primary closure (day 12). CONCLUSIONS: It is not possible to indicate clearly which surgical technique is superior to the other on the basis of the results obtained. When choosing the treatment method, the patient's clinical condition, associated anomalies and the medical team's experience must be taken into consideration.

The association between fluid restriction and hyponatremia in newborns with gastroschisis

Article

Mar 2021
AM J SURG

Introduction Newborns with gastroschisis require appropriate fluid resuscitation but are also at risk for hyponatremia that may lead to adverse outcomes. The etiology of hyponatremia in gastroschisis has not been defined. Methods Over a 24-month period, all newborns with gastroschisis in a free-standing pediatric hospital had sodium levels measured from serum, urine, gastric output, and the bowel bag around the eviscerated contents for the first 48 h of life. Total fluid intake and output were measured. Maintenance fluids were standardized at 120 ml/kg/day. Hyponatremia was defined as a serum sodium <132 mEq/L. A logistic regression model was created to determine independent predictors of hyponatremia. Results 28 infants were studied, and 14 patients underwent primary closure. While serum sodium was normal in all patients at birth, 9 (32%) infants developed hyponatremia at a median of 17.4 h of life. On univariate analysis, hyponatremic babies had a greater net positive fluid balance (74.9 vs 114.7 mL/kg, p = 0.001) primarily due to a decrease in total fluid output (p = 0.05). On multivariable regression, a 10 mL/kg increase in overall fluid balance was associated with an increased risk of developing hyponatremia (OR 1.84 [1.23, 3.45], p = 0.016). No differences in the sodium content of urine, gastric, or bowel bag fluid were observed, and sodium balance was equivalent between cohorts. Discussion Hyponatremia in babies with gastroschisis in the early postnatal period was associated with positive fluid balance and decreased fluid output. Prospective studies to determine the appropriate fluid resuscitation strategy in this population are warranted.

Accuracy of Ultrasound to Predict Neonatal Birth Weight Among Fetuses With Gastroschisis: Impact on Timing of Delivery

Article

Oct 2020

Objectives: To determine the accuracy of ultrasound estimation of fetal weight among fetuses with gastroschisis and how the diagnosis of fetal growth restriction (FGR) affects the timing of delivery. Methods: This was a retrospective cohort study including all fetuses with a diagnosis of gastroschisis at our institution from November 2012 through October 2017. We excluded multiple gestations, pregnancies with major structural or chromosomal abnormalities, and those for which prenatal and postnatal follow-up were unavailable. Performance characteristics of ultrasound to predict being small for gestational age (SGA) were calculated for the first and last ultrasound estimations of fetal weight. Results: Our cohort included 75 cases of gastroschisis. At the initial ultrasound estimation, 15 of 58 (25.9%) fetuses met criteria for FGR; 48 of 70 (68.6%) met criteria at the time of the last ultrasound estimation (median, 34.7 weeks). Cesarean delivery was performed for 37 of 75 (49.3%), with FGR and concern for fetal distress as the indication for delivery in 17 of 37 (45.9%). Only 6 of 17 (35.3%) of the neonates born by cesarean delivery for an indication of FGR and fetal distress were SGA. The initial ultrasound designation of FGR corresponded to SGA at birth in 8 of 15 (53.3%), whereas the last ultrasound estimation corresponded to SGA in 17 of 48 (35.4%). The initial ultrasound estimation agreed with the last ultrasound estimation before delivery with the diagnosis of FGR in 13 of 15 (86.7%). Conclusions: Ultrasound in the third trimester was sensitive but had a low positive predictive value and low accuracy for the diagnosis of SGA at birth for fetuses with gastroschisis. A large proportion of fetuses were born by cesarean delivery with indications related to FGR or fetal concerns.

Antenatal corticosteroids and outcomes in gastroschisis: A multicenter retrospective cohort study

Article

Full-text available

May 2020

Objective: In gastroschisis, there is evidence to suggest that gut dysfunction develops secondary to bowel inflammation; we aimed to evaluate the effect of maternal antenatal corticosteroids administered for obstetric reasons on time to full enteral feeds in a multicenter cohort study of gastroschisis infants. Methods: A three center, retrospective cohort study (1992-2013) with linked fetal/neonatal gastroschisis data was conducted. The primary outcome measure was time to full enteral feeds (a surrogate measure for bowel function) and secondary outcome measure was length of hospital stay. Analysis included Mann-Whitney and Cox regression. Results: Of 500 patients included in the study, 69 (GA at birth 34 [25-38] weeks) received antenatal corticosteroids and 431 (GA at birth 37 [31-41] weeks) did not. Antenatal corticosteroids had no effect on the rate of reaching full feeds (Hazard ratio HR 1.0 [95% CI: 0.8-1.4]). However, complex gastroschisis (HR 0.3 [95% CI: 0.2-0.4]) was associated with an increased time to reach full feeds and later GA at birth (HR 1.1 per week increase in GA [95% CI: 1.1-1.2]) was associated with a decreased time to reach full feeds. Conclusion: Maternal antenatal corticosteroids use, under current antenatal steroid protocols, in gastroschisis is not associated with an improvement in neonatal outcomes such as time to full enteral feeds or length of hospital stay. This article is protected by copyright. All rights reserved.

Development of a prenatal clinical care pathway for uncomplicated gastroschisis and literature review

Article

Mar 2020

Background: Gastroschisis is an abdominal wall defect wherein the bowel is herniated into the amniotic fluid. Controversy exists regarding optimal prenatal surveillance strategies that predict fetal well-being and help guide timing of delivery. Our objective was to develop a clinical care pathway for prenatal management of uncomplicated gastroschisis at our institution. Methods: We performed a review of literature from January 1996 to May 2017 to evaluate prenatal ultrasound (US) markers and surveillance strategies that help determine timing of delivery and optimize outcomes in fetal gastroschisis. Results: A total 63 relevant articles were identified. We found that among the US markers, intraabdominal bowel dilatation, polyhydramnios, and gastric dilatation are potentially associated with postnatal complications. Prenatal surveillance strategy with monthly US starting at 28weeks of gestational age (wGA) and twice weekly non-stress testing beginning at 32wGA is recommended to optimize fetal wellbeing. Timing of delivery should be based on obstetric indications and elective preterm delivery prior to 37wGA is not indicated. Conclusions: Close prenatal surveillance of fetal gastroschisis is necessary due to the high risk for adverse outcomes including intrauterine fetal demise in the third trimester. Decisions regarding the timing of delivery should take into consideration the additional prematurity-associated morbidity.

Effects of gestational age at delivery and type of labor on neonatal outcomes among infants with gastroschisis

Article

Aug 2019

Objective: To investigate the effect of preterm gestational age on neonatal outcomes of gastroschisis and to compare the neonatal outcomes after spontaneous labor versus iatrogenic delivery both in the preterm and early term gestational periods. Study design: A retrospective study of prenatally-diagnosed gastroschisis cases born at Loma Linda University Medical Center and Lucile Packard Children’s Hospital (CA, USA) between January 2009 and October 2016. A total of 194 prenatally diagnosed gastroschisis cases were identified and included in the analysis. We compared infants delivered < 37 0/7 to those ≥ 37 0/7 weeks’ gestation. Adverse neonatal outcome was defined as any of: sepsis, short bowel syndrome, prolonged ventilation or death. Prolonged length of stay (LOS) was defined as ≥ 75th percentile value. Outcomes following spontaneous versus iatrogenic delivery were compared. Analyses were performed using chi-squared test or Fisher’s exact test for categorical variables, and Student’s t-test or Wilcoxon rank-sum test for continuous variables. Results: One hundred six neonates were born < 37 weeks and 88 at ≥ 37 weeks. Adverse outcome was statistically similar among those born < 37 weeks compared to ≥ 37 weeks (48 versus 34%, p = 0.07). Prolonged LOS was more frequent among neonates delivered < 37 weeks (p = 0.03). Among neonates born < 37 weeks, bowel atresia was more frequent in those with spontaneous versus iatrogenic delivery (p = 0.04). There was no significant difference in the adverse neonatal composite outcome between those with spontaneous preterm labor versus planned iatrogenic delivery at < 37 weeks (n = 30 (58%) versus n = 21 (39%), p = 0.08). Conclusion: Neonates with gastroschisis delivered < 37 weeks had prolonged LOS whereas the rate of adverse neonatal outcomes was similar between those delivered preterm versus term. Neonates born after spontaneous preterm labor had a higher rate of bowel atresia compared to those born after planned iatrogenic preterm delivery.

Mode of delivery and mortality among neonates with gastroschisis: A population‐based cohort in Texas

Article

Full-text available

May 2019

Background Mode of delivery is hypothesised to influence clinical outcomes among neonates with gastroschisis. Results from previous studies of neonatal mortality have been mixed; however, most studies have been small, clinical cohorts and have not adjusted for potential confounders. Objectives To evaluate whether caesarean delivery is associated with mortality among neonates with gastroschisis. Methods We studied liveborn, nonsyndromic neonates with gastroschisis delivered during 1999‐2014 using data from the Texas Birth Defect Registry. Using multivariable Cox proportional hazards regression, we separately assessed the relationship between caesarean and death during two different time periods, prior to 29 days (<29 days) and prior to 365 days (<365 days) after delivery, adjusting for potential confounders. We also updated a recent meta‐analysis on this relationship, combining our estimates with those from the literature. Results Among 2925 neonates with gastroschisis, 63% were delivered by caesarean. No associations were observed between caesarean delivery and death <29 days (adjusted hazard ratio [aHR] 1.00, 95% confidence interval [CI] 0.63, 1.61) or <365 days after delivery (aHR 0.99, 95% CI 0.70, 1.41). The results were similar among those with additional malformations and among those without additional malformations. When we combined our estimate with prior estimates from the literature, results were similar (combined risk ratio [RR] 1.00, 95% CI 0.84, 1.19). Conclusions Although caesarean rates among neonates with gastroschisis were high, our results suggest that mode of delivery is not associated with mortality among these individuals. However, data on morbidity outcomes (eg intestinal damage, infection) were not available in this study.

Fetal anomalies

Chapter

Dec 2018

This chapter presents a case study of a 28‐year‐old nulliparous patient at 17 weeks gestational age, who wanted to know her chances for prenatal detection of major fetal anomalies as well as options for treatment and any potential risks to her or the fetus if a major anomaly is diagnosed. It presents the background, fetal surgery, delivery mode, fetal risks, pregnancy termination, and maternal risks associated with fetal anomalies. Patients with structural ultrasound anomalies, especially more than one major anomaly, should be offered diagnostic testing. Fetal surgery can be performed via open hysterotomy or minimally invasive techniques (fetoscopy) for a narrow set of indications involving anomalies such as neural tube defects, fetal lung lesions, congenital diaphragmatic hernia, skeletal dysplasias, sacrococcygeal teratomas, and obstructive uropathy. A retrospective cohort study spanning two decades at a single institution compared stillbirth rates between anomalous and nonanomalous pregnancies and noted stillbirth to be significantly higher for fetuses with anomalies.

Single center protocol driven care in 150 patients with gastroschisis 1998–2017: collaboration improves results

Article

Full-text available

Nov 2018
PEDIATR SURG INT

Purpose The treatment of gastroschisis (GS) using our collaborative clinical pathway, with immediate attempted abdominal closure and bowel irrigation with a mucolytic agent, was reviewed. Methods A retrospective review of the past 20 years of our clinical pathway was performed on neonates with GS repair at our institution. The clinical treatment includes attempted complete reduction of GS defect within 2 h of birth. In the operating room, the bowel is evaluated and irrigated with mucolytic agent to evacuate the meconium and decompress the bowel. No incision is made and a neo-umbilicus is created. Clinical outcomes following closure were assessed. Results 150 babies with gastroschisis were reviewed: 109 (77%) with a primary repair, 33 (23%) with a spring-loaded silo repair. 8 babies had a delayed closure and were not included in the statistical analysis. Successful primary repair and time to closure had a significant relationship with all outcome variables—time to extubation, days to initiate feeds, days to full feeds, and length of stay. Conclusion Early definitive closure of the abdominal defect with mucolytic bowel irrigation shortens time to first feeds, total TPN use, time to extubation, and length of stay.

The association between gestational age at delivery, closure type and perinatal outcomes in neonates with isolated gastroschisis

Article

Sep 2018

Objective: The objective of this study was to examine the association between gestational age at delivery and closure type for neonates with gastroschisis. In addition, we compared perinatal outcomes among cases of gastroschisis based on the following two factors: gestational age at delivery and abdominal wall closure technique. Methods: This was a retrospective cohort study of all fetuses with isolated gastroschisis that were diagnosed prenatally and delivered between September 2000 and January 2017, in a single tertiary care center. Neonates were compared based on the gestational age at the time of delivery: early preterm (less than 350/7 weeks), late preterm (350/7 – 366/7 weeks), and early term (370/6 – 386/7 weeks), using bivariate and multivariate analyses. The primary outcome was the type of abdominal wall closure: primary surgical closure or delayed closure using spring-loaded silo. Secondary outcomes included length of ventilatory support, length of parenteral nutrition, and length of hospital stay. Results: The analysis included 206 pregnancies complicated by gastroschisis. In univariate analysis, no differences were detected in primary closure rates of gastroschisis among the gestational age at delivery groups (67.4%, at < 35 weeks, 70.8% at 350/7 – 366/7 weeks, 73.7% at 370/6 – 386/7 weeks, p = 0.865). However, for every additional 100 grams of neonatal live birth weight there was an associated 9% increased odds of primary closure (OR 1.09, 95% CI 1.14–1.19, p = 0.04). Delivery in the early preterm period compared to the other two groups, was associated with longer duration of ventilation support and longer dependence on the parenteral nutrition. Neonates who underwent primary closure had shorter ventilation support, shorter time to initiation of enteral feeds and to discontinue parenteral nutrition, and shorter length of stay. In multivariate analyses, controlling for gestational age at delivery and presence of bowel atresia, primary closure continued to be associated with shorter duration of ventilation (by 5 days), earlier initiation of enteral feeds (by 7 days), shorter hospital stay (by 17 days) and lower odds of wound infection (OR = 0.37, 95% CI 0.15–0.97). Conclusions: Our study did not find an association between gestational age at delivery and the rates of primary closure of the abdominal wall defect; however later gestational age at delivery was associated with shorter duration of ventilatory support and parenteral nutrition dependence. In addition, we found that primary closure of gastroschisis, compared with delayed closure technique, was associated with improved neonatal outcomes, including shorter time to initiate enteral feeds and discontinue parenteral nutrition, shorter hospital stay, and lower risk of surgical wound infection. Therefore, postponing delivery of fetuses with gastroschisis until 37 weeks may be considered. Other factors besides the gestational age at delivery should be explored as predictors of primary closure in neonates with gastroschisis.

High-Risk Pregnancy

Article

Nov 2017

Cambridge Core - Obstetrics and Gynecology, Reproductive Medicine - High-Risk Pregnancy - edited by David James

National Practice Patterns for Prenatal Monitoring in Gastroschisis: Gastroschisis Outcomes of Delivery (GOOD) Provider Survey

Article

May 2018

Background: Gastroschisis is an abdominal wall defect with increasing incidence. Given the lack of surveillance guidelines among maternal-fetal medicine (MFM) specialists, this study describes current practices in gastroschisis management. Materials and methods: An online survey was administered to MFM specialists from institutions affiliated with the North American Fetal Therapy Network (NAFTNet). Questions focused on surveillance timing, testing, findings that changed clinical management, and delivery plan. Results: Responses were obtained from 29/29 (100%) NAFTNet centers, comprising 143/371 (39%) providers. The majority had a regimen for antenatal surveillance in patients with stable gastroschisis (94%; 134/141). Antenatal testing began at 32 weeks for 68% (89/131) of MFM specialists. The nonstress test (55%; 72/129), biophysical profile (50%; 63/126), and amniotic fluid index (64%; 84/131) were used weekly. Estimated fetal weight (EFW) was performed monthly by 79% (103/131) of providers. At 28 weeks, abnormal EFW (77%; 97/126) and Doppler ultrasound (78%; 99/127) most frequently altered management. In stable gastroschisis, 43% (60/140) of providers delivered at 37 weeks, and 29% (40/ 140) at 39 weeks. Discussion: Gastroschisis management differs among NAFTNet centers, although the majority initiate surveillance at 32 weeks. Timing of delivery still requires consensus. Prospective studies are necessary to further optimize practice guidelines and patient care.

Novel multidisciplinary approach to monitor and treat fetuses with gastroschisis using the Svetliza Reducibility Index and the EXIT-like procedure

Article

Full-text available

Dec 2017

Objective: To describe our initial experience with a novel approach to follow-up and treat gastroschisis in "zero minute" using the EXITlike procedure. Methods: Eleven fetuses with prenatal diagnosis of gastroschisis were evaluated. The Svetliza Reductibility Index was used to prospectively evaluate five cases, and six cases were used as historical controls. The Svetliza Reductibility Index consisted in dividing the real abdominal wall defect diameter by the larger intestinal loop to be fitted in such space. The EXIT-like procedure consists in planned cesarean section, fetal analgesia and return of the herniated viscera to the abdominal cavity before the baby can fill the intestines with air. No general anesthesia or uterine relaxation is needed. Exteriorized viscera reduction is performed while umbilical cord circulation is maintained. Results: Four of the five cases were performed with the EXIT-like procedure. Successful complete closure was achieved in three infants. The other cases were planned deliveries at term and treated by construction of a Silo. The average time to return the viscera in EXIT-like Group was 5.0 minutes, and, in all cases, oximetry was maintained within normal ranges. In the perinatal period, there were significant statistical differences in ventilation days required (p = 0.0169), duration of parenteral nutrition (p=0.0104) and duration of enteral feed (p=0.0294). Conclusion: The Svetliza Reductibility Index and EXIT-like procedure could be new options to follow and treat gastroschisis, with significantly improved neonatal outcome in our unit. Further randomized studies are needed to evaluate this novel approach.

Mode of delivery and outcomes of infants with gastroschisis: A meta-analysis of observational studies

Article

Full-text available

Sep 2017

Background There is controversy among the literature for electing caesarean section (CS) delivery for infants with gastroschisis in an attempt to reduce mortality and morbidity. Objective This meta-analysis investigates whether there is enough evidence to support CS delivery over vaginal delivery. Data sources We conducted our search in April 2017. We searched Cochrane, Medline, Premedline, Embase, CINAHL, GoogleScholar and Web of Science. We also searched conferences for abstracts online. Additional studies were retrieved by reviewing reference lists. Study selection Observational studies, excluding case series, were eligible if data compared relevant outcomes of infants with gastroschisis in relation to mode of delivery. Data extraction Relevant information were extracted and assessed the methodological quality of the retrieved records. Results Thirty-eight studies were included. Evidence suggested that mode of delivery is not significantly associated with overall mortality (OR 0.82, 95% CI 0.57 to 1.18), primary repair (OR 0.82, 95% CI 0.57 to 1.18), neonatal mortality (OR 1.08, 95% CI 0.54 to 2.15), necrotising enterocolitis, secondary repair, sepsis, short gut syndrome, duration until enteral feeding and duration of hospital stay. Furthermore, sensitivity analyses based on economic status and quality of study showed no significant difference between the impact of mode of delivery for all investigated outcomes. Limitations Due to uncontrolled variables between and within studies, particularly regarding characteristics of delivery and postdelivery care, it is difficult to extract meaningful results from the literature. Conclusions There is insufficient evidence to advocate the use of CS over vaginal delivery for infants with gastroschisis.

Outcomes of gastroschisis early delivery: A systematic review and meta-analysis

Article

Sep 2017

Background/purpose: Elective preterm delivery (EPD) of a fetus with gastroschisis may prevent demise and ameliorate intestinal injury. While the literature on optimal timing of delivery varies, we hypothesize that a potential benefit may be found with EPD. Methods: A meta-analysis of publications describing timing of delivery in gastroschisis from 1/1990 to 8/2016 was performed, including studies where either elective preterm delivery (group 1, G1) or preterm gestational age (GA) (group 2, G2) were evaluated against respective comparators. The following outcomes were analyzed: total parenteral nutrition (TPN), first enteral feeding (FF), length of stay, ventilator days, fetal demise, complex gastroschisis, sepsis, and death. Results: Eighteen studies describing 1430 gastroschisis patients were identified. G1 studies found less sepsis (p<0.01), fewer days to FF (p=0.03), and 11days less of TPN (p=0.07) in the preterm cohort. Comparatively, G2 studies showed less days to FF in term GA (p=0.02).Whereas G1 BWs were similar, G2 preterm had a significantly lower BW compared to controls (p=0.001). Conclusions: Elective preterm delivery appears favorable with respect to feeding and sepsis. However, benefits are lost when age is used as a surrogate of EPD. A randomized, prospective, multi-institutional trial is necessary to delineate whether EPD is advantageous to neonates with gastroschisis. Type of study: Treatment study. Level of evidence: Level III.

Gastrosquisis: momento e via do parto

Article

Dec 2015

Gastroschisis is a congenital abdominal wall defect in which bowel and other abdominal contents are herniated. The eviscerated loops are directly exposed to amniotic fluid which causes intestinal damage and neonatal mortality. Unless there is an obstetrical contraindication, delivery timing of gastroschisis foetuses should be extended at least to 37 weeks of gestation. Early elective delivery may result in prolonged time to enteral feeding and length of hospital stay as well as prematurity-related complications. There is no evidence that vaginal delivery results in additional morbidity in gastroschisis foetuses and caesarean section is recommended only for obstetrical indications.

Gastroschisis: A Review of Management and Outcomes

Article

Sep 2016

We performed an evidence-based review of the obstetrical management of gastroschisis. Gastroschisis is an abdominal wall defect, which has increased in frequency in recent decades. There is variation of prevalence by ethnicity and several known maternal risk factors. Herniated intestinal loops lacking a covering membrane can be identified with prenatal ultrasonography, andmaternal serum ?-fetoprotein level is commonly elevated. Because of the increased risk for growth restriction, amniotic fluid abnormalities, and fetal demise, antenatal testing is generally recommended. While many studies have aimed to identify antenatal predictors of neonatal outcome, accurate prognosis remains challenging. Delivery by 37 weeks appears reasonable, with cesarean delivery reserved for obstetric indications. Postnatal surgical management includes primary surgical closure, staged reduction with silo, or sutureless umbilical closure. Overall prognosis is good with low long-term morbidity in the majority of cases, but approximately 15% of cases are very complex with complicated hospital course, extensive intestinal loss, and early childhood death. Target Audience: Obstetricians, Maternal Fetal Medicine Providers, Certified Nurse Midwives, and Family Medicine Providers. Learning Objectives: After participating in this activity, the reader should be able to describe common pregnancy complications associated with gastroschisis; discuss options for prenatal and antenatal fetal surveillance; counsel parents regarding prenatal predictors of neonatal outcome and long-term prognosis; and describe the evidence-based recommendations for timing and mode of delivery.

Gastroschisis: Mortality risks with each additional week of expectant management

Article

Sep 2016

Background: Prior studies have evaluated the overall risk of stillbirth in pregnancies with fetal gastroschisis. However, the gestational age (GA) at which mortality is minimized, balancing the risk of stillbirth against neonatal mortality, remains unclear. Objective: To evaluate the GA at which pre- and postnatal mortality risk is minimized for fetuses with gastroschisis. Study design: Retrospective cohort study of singleton pregnancies delivered between 24 0/7 to 39 6/7 weeks, using 2005-2006 United States national linked birth and death certificate data. Among pregnancies with fetal gastroschisis, prospective risk of stillbirth and risk of infant death were determined for each GA week. Risk of infant death with delivery was further compared to composite fetal/infant mortality risk with expectant management for one additional week. Results: Among 2,119,049 pregnancies, 860 cases (0.04%) of gastroschisis were identified. The overall stillbirth rate among gastroschisis cases was 4.8%, and infant death occurred in 8.3%. Prospective risk of stillbirth became more consistently elevated beginning at 35 weeks, rising to 13.9 per 1,000 pregnancies (95% CI 10.8-17.1) at 39 weeks. Risk of infant death concurrently nadired in the third trimester, ranging between 62.4 and 66.8 per 1,000 live births between 32 and 39 weeks. Comparing mortality with expectant management versus delivery, relative risk (RR) was significantly greater with expectant management between 37 and 39 weeks, reaching 1.90 (95% CI 1.73-2.08) at 39 weeks with a number needed to deliver of 17.49 (95% CI 15.34-20.32) to avoid one excess death. Conclusion: Risk of pre- and postnatal mortality for fetuses with gastroschisis may be minimized with delivery as early as 37 weeks.

Strip of the Month: August 2016

Article

Aug 2016
NeoReviews

Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, the terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and was endorsed in 2005 by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). In 2008, ACOG, NICHD, and the Society for Maternal-Fetal Medicine reviewed and updated the definitions for fetal heart rate patterns, interpretation, and research recommendations. Following is a summary of the terminology definitions and assumptions found in the 2008 NICHD workshop report. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in Table 1. View this table: Table 1. Arterial Umbilical Cord Gas Values ### Assumptions from the NICHD Workshop ### Baseline Fetal Heart Rate

Delivery planning for pregnancies with gastroschisis: Findings from a prospective national registry

Article

Jun 2015

To determine the influence of planned mode and planned timing of delivery on neonatal outcomes in infants with gastroschisis STUDY DESIGN: Data from the Canadian Pediatric Surgery Network cohort were used to identify 519 fetuses with isolated gastroschisis delivering at all tertiary-level perinatal centers in Canada between 2005 and 2013 (n=16). Neonatal outcomes (including length of stay, duration of total parenteral nutrition, and a composite of perinatal death or prolonged exclusive total parenteral nutrition) were compared according to the 32-week planned mode and timing of delivery using multivariable quantile and logistic regression. Planned induction of labor was not associated with decreased length of stay (adjusted median difference -2.6 days, 95% CI: - 9.9, 4.8), total parenteral nutrition duration (0.2 days, 95% CI: - 6.4, 6.0), or risk of the composite adverse outcome (RR: 1.7, 95% CI: 0.1, 3.2) compared with planned vaginal delivery following spontaneous onset of labor. Planned delivery at 36-37 weeks was not associated with decreased length of stay (5.9 days, 95% CI: -5.7, 17.5), total parenteral nutrition duration (3.2 days, 95% CI: - 7.9, 14.3), or risk of composite outcome (RR: 2.3, 95% CI: 0.8, 5.4). Infants with gastroschisis delivered following planned induction or planned delivery at 36-37 weeks did not have significantly better neonatal outcomes than planned vaginal delivery following spontaneous onset of labour. Copyright © 2015 Elsevier Inc. All rights reserved.

Fetal lung maturity testing

Article

Aug 2014
AM J OBSTET GYNECOL

Dana P. Damron

Induction versus expectant monitoring for intrauterine growth restriction at term: Randomised equivalence trial (DIGITAT)

Article

Full-text available

Dec 2010
Br Med J

To compare the effect of induction of labour with a policy of expectant monitoring for intrauterine growth restriction near term. Multicentre randomised equivalence trial (the Disproportionate Intrauterine Growth Intervention Trial At Term (DIGITAT)). Eight academic and 44 non-academic hospitals in the Netherlands between November 2004 and November 2008. Pregnant women who had a singleton pregnancy beyond 36+0 weeks' gestation with suspected intrauterine growth restriction. Induction of labour or expectant monitoring. The primary outcome was a composite measure of adverse neonatal outcome, defined as death before hospital discharge, five minute Apgar score of less than 7, umbilical artery pH of less than 7.05, or admission to the intensive care unit. Operative delivery (vaginal instrumental delivery or caesarean section) was a secondary outcome. Analysis was by intention to treat, with confidence intervals calculated for the differences in percentages or means. 321 pregnant women were randomly allocated to induction and 329 to expectant monitoring. Induction group infants were delivered 10 days earlier (mean difference -9.9 days, 95% CI -11.3 to -8.6) and weighed 130 g less (mean difference -130 g, 95% CI -188 g to -71 g) than babies in the expectant monitoring group. A total of 17 (5.3%) infants in the induction group experienced the composite adverse neonatal outcome, compared with 20 (6.1%) in the expectant monitoring group (difference -0.8%, 95% CI -4.3% to 3.2%). Caesarean sections were performed on 45 (14.0%) mothers in the induction group and 45 (13.7%) in the expectant monitoring group (difference 0.3%, 95% CI -5.0% to 5.6%). In women with suspected intrauterine growth restriction at term, we found no important differences in adverse outcomes between induction of labour and expectant monitoring. Patients who are keen on non-intervention can safely choose expectant management with intensive maternal and fetal monitoring; however, it is rational to choose induction to prevent possible neonatal morbidity and stillbirth. International Standard Randomised Controlled Trial number ISRCTN10363217.

Review of the evidence on the closure of abdominal wall defects

Article

Full-text available

Dec 2010
PEDIATR SURG INT

Infants with congenital abdominal wall defects pose an interesting and challenging management issue for surgeons. We attempt to review the literature to define the current treatment modalities and their application in practice. In gastroschisis, the overall strategies for repair include immediate closure or delayed operative repair. The best level of data for gastroschisis is grade C and appears to support that there is no major difference in survival between immediate closure or delayed repair. In patients with omphalocele, the management techniques are more varied consisting of immediate closure, staged closure or delayed closure after epithelialization. The literature is less clear on when to use one technique over the other, consisting of mostly grade D and E data. In patients with omphalocele, a registry to collect information on patients with larger defects may help determine which of the management strategies is optimal.

Gastroschisis: An update

Article

Full-text available

Sep 2010
PEDIATR SURG INT

Gastroschisis (GS) continues to increase in frequency, with several studies now reported an incidence of between 4 and 5 per 10,000 live births. The main risk factor would seem to be young maternal age, and it is in this group that the greatest increase has occurred. Whilst various geographical regions confer a higher risk, the impact of several other putative risk factors, including smoking and illicit drug use, may be less important than when first identified in early epidemiological studies. Over 90% of cases of GS will now be diagnosed on antenatal ultrasound, but its value in determining the need for early delivery remains unclear. There would appear no clear evidence for either routine early delivery or elective caesarean section for infants with antenatally diagnosed GS. Delivery at a centre with paediatric surgical facilities reduces the risk of subsequent morbidity and should represent the standard of care. The relative roles of primary closure, staged closure and ward reduction, with or without general anaesthesia, appear less clear with considerable variation between centres in both the use of these techniques and subsequent surgical outcomes. Survival rates continue to improve, with rates well in excess of 90% now routine. The limited long-term developmental data available would suggest that normal or near-normal outcomes may be expected although there remains a need for further studies.

Gastroschisis: Preterm or term delivery?

Article

Full-text available

Feb 2010

The main objective of this study was to evaluate the association between prematurity and the time to achieve full enteral feeding in newborns with gastroschisis. The second objective was to analyze the associations between length of hospital stay and time to achieve full enteral feeding with mode of delivery, birth weight and surgical procedure. The medical records of newborns with gastroschisis treated between 1997 and 2007 were reviewed. Two groups were considered: those delivered before 37 weeks (group A) and those delivered after 37 weeks (group B). The variables of gestational age, mode of delivery, birth weight, time to achieve full enteral feeding, length of hospital stay and surgical approach were analyzed and compared between groups. Forty-one patients were studied. In Group A, there were 14 patients with a mean birth weight (BW) of 2300 g (range=1680-3000) and a mean gestational age (GA) of 36 weeks (range=34-36). In group B, there were 24 patients with a mean BW of 2700 g (range=1500-3550) and a mean GA of 38 weeks (range=37-39). The mean time to achieve full enteral feeding was 30.1+/-6.7 days in group A and 17.0+/-2.5 days in group B (p=0.09) with an OR of 0.82 and a 95% CI of 0.20-3.23 after adjustment for sepsis and BW. No statistical difference was found between low BW (<2500 g), mode of delivery and number of days to achieve full enteral feeding (p=0.34 and p=0.13, respectively). Patients with BW over 2500 g had fewer days in the hospital (22.9+/-3.1 vs. 35.7+/-5.7 days; p=0.06). The results of this study do not support the idea of anticipating the delivery of fetuses with gastroschisis in order to achieve full enteral feeding earlier.

Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial

Article

Full-text available

Aug 2009
LANCET

Robust evidence to direct management of pregnant women with mild hypertensive disease at term is scarce. We investigated whether induction of labour in women with a singleton pregnancy complicated by gestational hypertension or mild pre-eclampsia reduces severe maternal morbidity. We undertook a multicentre, parallel, open-label randomised controlled trial in six academic and 32 non-academic hospitals in the Netherlands between October, 2005, and March, 2008. We enrolled patients with a singleton pregnancy at 36-41 weeks' gestation, and who had gestational hypertension or mild pre-eclampsia. Participants were randomly allocated in a 1:1 ratio by block randomisation with a web-based application system to receive either induction of labour or expectant monitoring. Masking of intervention allocation was not possible. The primary outcome was a composite measure of poor maternal outcome--maternal mortality, maternal morbidity (eclampsia, HELLP syndrome, pulmonary oedema, thromboembolic disease, and placental abruption), progression to severe hypertension or proteinuria, and major post-partum haemorrhage (>1000 mL blood loss). Analysis was by intention to treat and treatment effect is presented as relative risk. This study is registered, number ISRCTN08132825. 756 patients were allocated to receive induction of labour (n=377 patients) or expectant monitoring (n=379). 397 patients refused randomisation but authorised use of their medical records. Of women who were randomised, 117 (31%) allocated to induction of labour developed poor maternal outcome compared with 166 (44%) allocated to expectant monitoring (relative risk 0.71, 95% CI 0.59-0.86, p<0.0001). No cases of maternal or neonatal death or eclampsia were recorded. Induction of labour is associated with improved maternal outcome and should be advised for women with mild hypertensive disease beyond 37 weeks' gestation. ZonMw.

Is Preterm Delivery Indicated in Fetuses with Gastroschisis and Antenatally Detected Bowel Dilation?

Article

Jul 2012
FETAL DIAGN THER

Introduction: Due to the controversy surrounding diagnostic ultrasound evaluations and elective preterm delivery of fetuses with gastroschisis, we sought to calculate the predictive value of bowel dilation in fetuses with gastroschisis and evaluate the effect of preterm delivery on neonatal outcomes. Materials and methods: Ultrasounds and medical records of 103 mother-infant pairs with fetal gastroschisis were reviewed. Eighty-nine pairs met the criteria. Intestinal complications, gestational age at delivery, birth weight, and number of abdominal surgeries were documented. Results: Forty-eight fetuses (54%) had bowel dilation and 41 (46%) did not. The positive predictive value of bowel dilation for complicated gastroschisis was 21%. There were 50 (56%) preterm and 39 (44%) term deliveries. The mean birth weight was 2,114 g (SD = 507) and 2,659 g (SD = 687), p = 0.001. For infants delivered preterm, the mean number of postnatal abdominal surgeries was 2.1 (SD = 1.1) as compared to 1.3 (SD = 0.5) surgical procedures for those infants delivered at term gestation. This was not statistically significant. With respect to hospital stay for each group, the mean length of neonatal intensive care unit admission was 48 days (SD = 33) in the preterm group and 35 days (SD = 50) in the term group, which was not statistically significant. Discussion: Ultrasound-detected bowel dilation was not predictive of important intestinal complications. Our data did not substantiate any benefit for elective preterm delivery of neonates with gastroschisis.

Early elective cesarean delivery before 36 weeks vs late spontaneous delivery in infants with gastroschisis

Article

Jul 2008
J PEDIATR SURG

The aim of this study is to assess the value of early elective cesarean delivery for patients with gastroschisis in comparison with late spontaneous delivery. Analysis of infants with gastroschisis admitted between 1986 and 2006 at a tertiary care center was performed. The findings were analyzed statistically. Eighty-six patients were involved in the study. This included 15 patients who underwent emergency cesarean delivery (EM CD group) because of fetal distress and/or bowel ischemia. The remaining 71 patients born electively were stratified into 4 groups. The early elective cesarean delivery (ECD) group included 23 patients born by ECD before 36 weeks; late vaginal delivery (LVD) group included 23 patients who had LVD after 36 weeks; 24 patients had LCD after 36 weeks because of delayed diagnosis that resulted in late referral; and 1 patient had early spontaneous vaginal delivery (EVD group) before 36 weeks. The mean time to start oral feeding, incidence of complications, and primary closure were significantly better in the ECD group than in the LVD group. The duration of ventilation and the length of stay were shorter in ECD group, but the difference was not statistically significant. Elective cesarean delivery before 36 weeks allows earlier enteral feeding and is associated with less complications and higher incidence of primary closure (statistically significant).

Neonatal abdominal Wall defects

Article

Jun 2011

Effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes

Article

Aug 2011
J PEDIATR SURG

This study examined the effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes, with adjustment for key confounding variables. This retrospective cohort study included all gastroschisis patients treated at a single tertiary children's hospital between 1999 and 2009. Prenatal care, delivery mode (vaginal vs cesarean section before labor vs after labor), patient characteristics, and clinical outcomes were determined by chart review. Time to discontinuation of parenteral nutrition (PN) was the primary outcome of interest. Effects of multidisciplinary prenatal care and delivery mode were evaluated using Cox proportional hazards regression models that included gestational age, birth weight, sex, concomitant intestinal complications, and year of admission. Of 167 patients included, 46% were delivered vaginally, 69% received multidisciplinary prenatal care, and median time to PN discontinuation was 38 days. On multivariable modeling, gestational age, uncomplicated gastroschisis, and year of admission were significant predictors of early PN independence. Delivery mode and prenatal care had no independent effect on outcomes, although patients receiving multidisciplinary prenatal care were more likely to be born at term (49% vs 27%, P = .01). Gestational age and intestinal complications are the major determinants of outcome in gastroschisis. Multidisciplinary prenatal care may facilitate term delivery.

Preterm elective caesarean section and early enteral feeding in gastroschisis

Article

Jan 2011
ACTA PAEDIATR

To evaluate the effect of elective caesarean section (CS) before term and early enteral nutrition on length of parenteral nutrition and hospital stay in infants with gastroschisis. Retrospective review of all infants with gastroschisis treated in a regional level III hospital from 1993 to 2008. During 1993-97, there was no established standard for management of pregnancy or delivery while a protocol on close foetal monitoring and early elective CS was adhered to for 1998-2008. Introduction of human milk on the first day after complete closure of the abdominal wall and rapid increase was the policy during the whole period. With early elective CS, no foetal deaths occurred after 28-week gestational age (GA). Ten infants were born during the first period and 20 during the second period at a median GA (range) of 36.5 (34-40) and 35 (34-37) weeks (p = 0.013). Seven and 20, respectively, were born by CS. Median (range) days before full enteral feeds and hospital stay were 11.5 (7-39) and 13.0 (7-46) (p = 0.85), and 17.5 (12-36) and 22.5 (13-195) (p = 0.67), respectively. One child died of volvulus after discharge. Close surveillance of pregnancy, elective preterm caesarean section, early surgery and active approach to primary closure and early enteral feeds appears to be a safe and effective line of management in gastroschisis.

Delivery of gastroschisis patients before 37 weeks of gestation is associated with increased morbidities

Article

Aug 2009
J PEDIATR SURG

Despite advances in the care of neonates with gastroschisis, patients present with significant morbidities. Preterm delivery of neonates with gastroschisis is often advocated to avoid the intestinal damage that may be sustained with prolonged exposure to amniotic fluid. However, preterm delivery may impose additional morbidities to this disease process. We conducted a retrospective review of patients with gastroschisis born from 1989 to 2007. Demographic and clinical data were collected. Preterm healthy neonates, with gestational age from 26 to 36 weeks, were used as controls. Preterm infants with gastroschisis had a 14 times higher risk for any of the recorded morbidities. As compared to term neonates with gastroschisis, preterm neonates with gastroschisis had a higher rate of sepsis, longer duration to reach full enteral feedings, and longer length of stay. Although the preterm infants with gastroschisis were less likely to be small for gestational age at birth, they were as likely as the term infants with gastroschisis to have failure to thrive at discharge and had a greater drop in weight percentile during hospitalization. Preterm delivery should be avoided because there is no clear benefit to the gut in avoiding derivative injuries. Meticulous attention should be given to the nutritional needs of patients with gastroschisis.

Is timing everything? The influence of gestational age, birth weight, route, and intent of delivery on outcome in gastroschisis

Article

Jun 2009
J PEDIATR SURG

Optimal perinatal treatment in gastroschisis remains uncertain. We sought to determine the effect of gestational age (GA), birth weight (BW), and intended and actual route of delivery on outcomes in gastroschisis. Cases were abstracted from a national gastroschisis database. Outcomes analyzed by route of delivery, delivery plan conformity, BW, and GA included survival, closure success, ventilation days, total parenteral nutrition days, and length of hospital stay. Logistic regression for continuous and categorical variables was performed. One hundred ninety-two babies (56% male) born at mean GA of 36.1 +/- 2.1 weeks, with mean BW of 2536 +/- 557 g, were included. One hundred eighty-three (95%) survived. Of 145 pregnancies with an antenatal delivery plan, vaginal delivery was intended in 77% and actually occurred in 119 pregnancies, with the remainder being planned (33; 17%) or emergency (40; 21%) cesarean deliveries. A delivery conforming to the antenatal plan occurred in 74 (51%). Birth weight and GA were significant inverse predictors of ventilator and total parenteral nutrition days and length of hospital stay, but not survival. Delivery route did not predict any outcome; however, "nonconformers" were born at lower BW and GA than "conformers," and they showed trends toward poorer nonmortality outcomes. Gestational age, BW, and conformity to an antenatal birth plan are predictors of outcome in gastroschisis, whereas actual route of delivery is not.

Mode of delivery and neonatal survival of infants with gastroschisis in Australia and New Zealand

Article

Oct 2008
J PEDIATR SURG

The aim of the study was to examine the short-term outcome of infants with gastroschisis by route of delivery, comparing vaginal delivery vs elective and emergency cesarean delivery (CD). Six hundred thirty-one infants with gastroschisis (International Classification of Diseases, 10th Revision: Q79.3) were admitted to the Australian and New Zealand Neonatal Network during 1997 to 2005. Multivariate Cox proportional hazards regression analysis was performed to adjust for case-mix and significant baseline characteristics. During the study period, 631 infants with gastroschisis were admitted to the collaborating centers. Of these, 343 (54.4%) infants were delivered vaginally, whereas 288 (45.6%) were delivered by cesarean birth. Of the latter, 148 (23.4%) were elective and 140 (22.2%) were emergency. There was an increasing trend of CD from 41.1% in 1997 to 69.0% in 2005. Forty-seven (7.4%) infants died; 30 (8.7%) in the vaginal, 9 (6.4%) in the emergency, and 8 (5.4%) in the elective CD group. There was no difference in rate of proven infection, duration of ventilation, or length of neonatal intensive care unit stay between the 3 groups. After controlling for prematurity, low birth weight, and outborn birth, the risk for neonatal demise was similar in both the vaginal and CD infants (adjusted hazard ratio, 1.486; 95% confidence interval, 0.814-2.713; P = .197). Stratifying the CD (emergency vs elective) gave similar results. Infants with gastroschisis appear to be safely delivered vaginally.

Scheduled preterm delivery for gastroschisis improves postoperative outcome

Article

Sep 2008

There are some evidence to suggest that careful antenatal monitoring, scheduled preterm delivery and immediate abdominal wall closure may reduce gastroschisis morbidity. We hypothesised that the advantages of a scheduled preterm delivery balance possible complications related to prematurity. A retrospective study was performed including all cases of gastroschisis born between 1990 and 2004 (n = 69). Cases were categorised in two groups. Group 1 contained gastroschisis cases born between 1990 and 1997. Group 2 contained cases occurring since 1997, when a new management pathway for gastroschisis was established: weekly evaluation of the foetal gut by ultrasound (>28 weeks), corticosteroids, and delivery by scheduled caesarean section at 35 weeks (before if evidence of bowel compromise was present). The primary endpoints of this study were the initiation of oral feeding and the number of re-operation for intestinal obstruction. There was a significantly faster initiation of oral feeding (P < 0.0001), however, duration of parenteral nutrition (34 vs. 38 days) and hospital discharge (53 vs. 58.5 days) was not reduced. There was no complication due to prematurity in group 2. Postoperative outcome was improved with less need for muscular stretching or prosthetic patch and less re-operation for intestinal obstruction (P < 0.05). Scheduled and elective preterm delivery facilitates surgical procedure and shortens the time to first feeding. A delivery at 35 weeks (preferring vaginal delivery) seems to be a good compromise between risks related to prematurity and complications related to intestinal peel.

The importance of serial biophysical assessment of fetal well-being in gastroschisis

Article

Nov 1992
Br J Obstet Gynaecol

To review antenatal and intrapartum assessment of pregnancies complicated by gastroschisis. Retrospective descriptive study. University College Hospital, London. 24 consecutive cases of gastroschisis between 1986 and 1991. The gestational age at sonographic diagnosis was 20.3 weeks (SD 6.77) and at birth was 36.5 weeks (SD 2.06). There were 21 live births, all with good surgical outcome. There were 16 vaginal deliveries and eight caesarean sections. The elective sections were for oligohydramnios and dilated bowel (1) and clinically suspected growth retardation (1); the intrapartum caesarean sections were for fetal distress (4) and premature breech presentation (2). There were six with dilated gut on ultrasound; one of these ended in a stillbirth. There was a significant association between gut dilatation and caesarean section for fetal distress (P = 0.004). There was also a significant association between meconium staining and fetal distress (P = 0.021). Of these babies, 46% were < or = third centile for corrected birth weight. While half of the babies with gastroschisis were small for gestational age at birth, reliable antenatal prediction of birth weight is difficult. Gut dilatation may be an indicator of either antenatal or intrapartum fetal distress, but does not correlate with poor neonatal surgical outcome. We suggest close antenatal surveillance of fetal wellbeing in all cases of gastroschisis because, in addition to growth retardation, many show some evidence of fetal distress and 12.5% end in stillbirth, even when appropriately grown.

Etiology of intestinal damage in gastroschisis. I: Effects of amniotic fluid exposure and bowel constriction in a fetal lamb model

Article

Nov 1989

Gastroschisis is often complicated by damage to the herniated small bowel, resulting in motility and absorption disturbances and occasional intestinal necrosis and atresia. To study the pathophysiology of this process, a model of gastroschisis was developed in fetal lambs. At 80 days' gestation, the anterior abdominal wall was partially excised to create a small peritoneal cavity, and the small bowel was extruded through a Silastic ring to create a defect of uniform size. In one experimental group, a tie was placed around the herniated bowel at the level of the abdominal wall to provide gradual constriction as the fetus grew. In a second group, no tie was placed. Control animals had a simple laparotomy and no abdominal wall defect; some also had a constrictor placed around the base of the bowel. The animals were delivered near term, and the bowel was evaluated histologically and by an in-vitro bowel motility assay. Histologic examination showed normal ganglion cells in all groups and no evidence of ischemic injury. A fibrous peel was seen only in bowel exposed to amniotic fluid, with or without a constrictor. Lymphatic and venous dilation, smooth-muscle thickening, and focal mucosal blunting were seen in bowel subjected to chronic obstruction by a constrictor, regardless of whether it was exposed to amniotic fluid. Both constriction of the bowel and amniotic fluid exposure were associated with a decrease in motility; these two effects were independent and additive.(ABSTRACT TRUNCATED AT 250 WORDS)

Severity of intestinal damage in gastroschisis: Correlation with prenatal sonographic findings

Article

Jul 1988

From 1982 to 1986, 26 abdominal wall defects were detected prenatally. Seventeen pregnancies culminated in live births with ultrasound correctly distinguishing between omphalocele and gastroschisis in all cases. In the 11 cases of gastroschisis diagnosed before birth, we attempted to correlate the clinical outcome with the size of the abdominal wall defect, sonographic appearance of the eviscerated bowel, and known time of exposure to amniotic fluid (gestational age at birth to gestational age at diagnosis). Neither the time of exposure to amniotic fluid (median duration of 14 weeks) nor the defect size could be correlated with eventual clinical outcome. The presence of small bowel dilatation and mural thickening on prenatal sonography (four patients) had a high correlation with severe intestinal damage and poor clinical outcome. The absence of these two sonographic findings (seven patients) was associated with mild intestinal changes and benign clinical course with no morbidity or mortality. We conclude that obstetric ultrasound cannot only accurately detect the presence and type of abdominal wall defect, but it also gives an indication of the severity of intestinal damage and subsequent clinical course in prenatally diagnosed cases of gastroschisis. Early delivery of the fetus with prenatally diagnosed gastroschisis should no longer be performed to limit exposure to amniotic fluid. Now that reliable sonographic criteria of severe intestinal damage have been defined, the decision to deliver early can be restricted to those fetuses with bowel dilatation and mural thickening.

Elective Caesarean section improves outcomes of neonates with gastroschisis

Article

Nov 1993
AM J OBSTET GYNECOL

Our objective was to compare neonatal postoperative morbidity for the neonate with prenatally diagnosed gastroschisis delivered vaginally with that for the perinate undergoing elective cesarean at or before the onset of labor. Retrospective maternal and neonatal data were obtained by chart review on 22 neonates prenatally diagnosed with gastroschisis who underwent operative closure of the ventral wall defect between 1987 and 1991 at Loma Linda University Medical Center. Perioperative data and postoperative courses were compared between 12 infants who underwent labor with vaginal delivery and 10 infants who were delivered by elective cesarean section at or before the onset of labor. Neonatal transports and significant bowel edema were more likely (p < 0.05) in the vaginal delivery group. The elective cesarean section infants had less sepsis (p < 0.05), fewer hospital days (p < 0.01) and parenteral nutrition days (p < 0.01), and shorter time to enteral feedings (p < 0.01). Elective cesarean section at or before the onset of labor may benefit the fetus with gastroschisis, compared with undergoing labor and vaginal delivery.

Insulin-requiring diabetes in pregnancy: A randomized trial of active induction of labor and expectant management

Article

Oct 1993
AM J OBSTET GYNECOL

Our purpose was to assess whether a program of expectant management of uncomplicated pregnancies in mothers with insulin-requiring gestational or pregestational class B reduces the incidence of cesarean birth. Two hundred women with uncomplicated, insulin-requiring diabetes at 38 weeks' gestation who were compliant with care and whose infants were judged appropriate for gestational age were randomly assigned to (1) active induction of labor within 5 days or (2) expectant management. The expectant management group was monitored with weekly physical examination and twice-weekly nonstress tests and amniotic fluid volume estimation until delivery. Expectant management increased the gestational age at delivery by 1 week. Approximately half (49%) of the mothers in the expectant management group required induction of labor for obstetric indications. The cesarean delivery rate was not significantly different in the expectant management group (31%) from the active induction group (25%). The mean birth weight (3672 +/- 407 gm) and percentage large for gestational age, as defined by birth weight > or = 90th percentile, of infants in the expectantly managed group (23%) was greater than those in the active induction group (3466 +/- 372 gm, p < 0.0001, 10% large for gestational age). This difference persisted after controlling for gestational age and maternal age and body weight (p < 0.01). In women with uncomplicated insulin-requiring gestational or class B pregestational diabetes, expectant management of pregnancy after 38 weeks' gestation did not reduce the incidence of cesarean delivery. Moreover, there was an increased prevalence of large-for-gestational-age infants (23% vs 10%) and shoulder dystocia (3% vs 0%). Because of these risks, delivery should be contemplated at 38 weeks and, if not pursued, careful monitoring of fetal growth must be performed.

The effect of gestational age at birth on morbidity in patients with gastroschisis

Article

Sep 1996

Infants born with gastroschisis frequently present with an eviscerated intestinal segment that is inflamed and thickened. The damaged segment of intestine displays absorption and motility disturbances for a variable period of time after gastroschisis repair. Clinical and animal research suggests that the damage to the eviscerated intestine is caused by prolonged exposure to amniotic fluid and/or progressive constriction on the intestine and its blood supply by the umbilical ring. Some obstetricians and pediatric surgeons have advocated early elective delivery to decrease the exposure of the bowel to these potentially damaging influences. Fifty-five patients underwent gastroschisis repair at the authors' institution during the last 6 years. Many of these patients had early elective delivery after their pulmonary maturity was judged adequate based on their amniotic lecithin/sphingomyelin ratios. The patients were divided into three groups according to gestational age at the time of delivery. Elective early delivery did not lessen the need for silo closure or hasten the time until enteral feeding could be tolerated. The hospital stay was not shortened for the early delivery group. This retrospective review supports the concept that patients with sonographically identified antenatal gastroschisis are best managed by delivery at full term.

Adverse outcome after prenatal diagnosis of gastroschisis: The role of fetal monitoring

Article

Apr 1997

Fifty-seven fetuses with gastroschisis presented between 1982 and 1995 were studied by retrospective review of medical records. There were three late intrauterine deaths (IUD). Fetal distress, as determined by reduced fetal movements or abnormal cardiotopograph (CTG), was encountered in 23 of the 54 liveborn infants (43%), all of whom had delivery expedited either by emergency caesarean section (n = 19) or induction (n = 4). Six infants had abnormal neurological outcome: two died in the neonatal period of severe perinatal brain injury, neonatal fits were observed in four, two of whom developed cerebral palsy, and one died at the age of 7 years. All six of these infants had suffered fetal distress. If the three intrauterine deaths are included, 16% of all cases were associated with abnormal neurological outcome. The introduction of regular CTG monitoring from 32 weeks' gestation in 1990 increased the ability to detect fetal distress twofold. This resulted in a similar increase in obstetric intervention and an associated reduction in adverse neurological outcome. Pregnancies associated with gastroschisis should be considered at significant risk of fetal distress, which itself may culminate in late intrauterine death, neonatal death, or adverse neurological outcome. Careful, repeated fetal monitoring in the third trimester is indicated.

The influence of gestational age and mode of delivery on infants with gastroschisis

Article

Oct 1999

It has been proposed that preterm and prelabor cesarean section may improve the outcome of infants with gastroschisis. The purpose of this study is to examine the impact of gestation and delivery method on infants with gastroschisis. The medical records of 60 infants with gastroschisis treated at a tertiary care center from 1985 through 1995 were reviewed retrospectively. The gestational age, the mode of delivery, the type of operative repair, and the length of hospital stay were recorded for each patient. Infants born vaginally were more likely to require silo stage repair than those delivered by cesarean section (21 of 29 v. 11 of 31, P<.01). Infants born vaginally also had longer hospital stay than those delivered by cesarean section (53 v. 39 days, P = .19). Infants born before 33 weeks' of gestation stayed longer in the hospital than those born after 33 weeks. After 33 weeks' gestation, infants had similar hospital stay regardless of the gestational age. Cesarean section delivery was beneficial for infants with gastroschisis. Preterm delivery did not shorten the length of hospital stay. The role of elective cesarean section delivery at term should be considered for infants with gastroschisis diagnosed antenatally.

Evaluation of prenatal ultrasound diagnosis of fetal abdominal wall defects by 19 European registries

Article

Nov 2001

To evaluate the current effectiveness of routine prenatal ultrasound screening in detecting gastroschisis and omphalocele in Europe. Data were collected by 19 congenital malformation registries from 11 European countries. The registries used the same epidemiological methodology and registration system. The study period was 30 months (July 1st 1996-December 31st 1998) and the total number of monitored pregnancies was 690,123. The sensitivity of antenatal ultrasound examination in detecting omphalocele was 75% (103/137). The mean gestational age at the first detection of an anomaly was 18 +/- 6.0 gestational weeks. The overall prenatal detection rate for gastroschisis was 83% (88/106) and the mean gestational age at diagnosis was 20 +/- 7.0 gestational weeks. Detection rates varied between registries from 25 to 100% for omphalocele and from 18 to 100% for gastroschisis. Of the 137 cases of omphalocele less than half of the cases were live births (n = 56; 41%). A high number of cases resulted in fetal deaths (n = 30; 22%) and termination of pregnancy (n = 51; 37%). Of the 106 cases of gastroschisis there were 62 (59%) live births, 13 (12%) ended with intrauterine fetal death and 31 (29%) had the pregnancies terminated. There is significant regional variation in detection rates in Europe reflecting different policies, equipment and the operators' experience. A high proportion of abdominal wall defects is associated with concurrent malformations, syndromes or chromosomal abnormalities, stressing the need for the introduction of repeated detailed ultrasound examination as a standard procedure. There is still a relatively high rate of elective termination of pregnancies for both defects, even in isolated cases which generally have a good prognosis after surgical repair.

Benefits of Term Delivery in Infants With Antenatally Diagnosed Gastroschisis

Article

Oct 2002
OBSTET GYNECOL

To test the hypothesis that term gestation offers the best outcome. The relationship between gestational age and the extent of bowel injury in fetuses with gastroschisis is a matter of debate. Early delivery and cesarean delivery have been recommended to limit intestinal damage, but their benefits are unclear. Data on all patients with gastroschisis seen at our institution from 1991 through 2001 were included. Patients were compared based on gestational age: less than 35 weeks, 35-37 weeks, and term (more than 37 weeks) with regard to age at definitive closure, age at first and full feedings, and hospital stay. Statistical significance (P <.05) was determined by analysis of variance and chi(2) analysis. Of the 57 patients, 19.3%, 43.8%, and 36.9% were born at less than 35 weeks, 35-37 weeks, and more than 37 weeks, respectively. Age at definitive closure was significantly higher at 35-37 weeks (5.9 +/- 4.6 days) than at more than 37 weeks (1.5 +/- 2.3 days) and less than 35 weeks (2.6 +/- 2.5 days) (P <.05). A prosthetic pouch (silo) was used more often at 35-37 weeks than at more than 37 weeks or less than 35 weeks (P =.03, chi(2)). Age at first (P =.04) and full feedings (P <.01) and length of hospitalization (P <.01) were all significantly higher at 35-37 weeks than at more than 37 weeks. Based on a homogeneous cohort of patients in whom gastroschisis was diagnosed antenatally, term delivery results in earlier closure of the defect and shorter time to full feedings. The benefit of early delivery postulated by others cannot be substantiated.

Gastroschisis: Small hole, big cost

Article

Dec 2002
J PEDIATR SURG

This study was designed to assess the outcome and financial costs incurred for the treatment of gastroschisis. A retrospective analysis was conducted of all patients with gastroschisis at a single institution over the past decade (n = 69). Hospital costs were determined and standardized to December 2001 dollars. Of the 69 patients, average gestational age at delivery was 35.9 weeks. Thirty-six patients had a primary fascial closure; 33 had a silo placed. The mean time to first feeding was 22 days and full feeding, 33 days. Average length of stay was 47 days. There were 3 deaths (2 shortly after birth, and one 131 days later owing to sepsis). The average cost of hospitalization and physician fees for patients with gastroschisis was $123,200. Using multivariate regression analysis, significant variables (P <.05) associated with cost of hospitalization were number of operative procedures, ventilatory days, male gender, and length of stay. Room expenses (43%), physician fees (15%), respiratory and pulmonary care (10%), and supply and devices (10%) made up the majority of costs. Cost of care associated with treatment for gastroschisis is high. Strategies designed to reduce cost must limit gastrointestinal, respiratory, and operative complications and reduce length of stay.

A Prospective Trial of Elective Preterm Delivery for Fetal Gastroschisis

Article

Jul 2004

To test the hypothesis that preterm delivery of fetal gastroschisis prevents serious gastrointestinal compromise, facilitates primary surgical closure, and improves surgical outcome, we enrolled 16 women in a management plan. This included high-resolution ultrasound, weekly re-evaluation of the fetal gut (> or = 26 weeks), corticosteroids, and delivery if evidence of bowel compromise was present > 30 weeks. These fetuses were compared with 16 consecutive patients treated prior to establishment of this plan. Comparison of prospective trial patients with controls revealed significant differences in age at delivery (34.2 versus 37.7 weeks), serious bowel compromise (0 versus 70%), use of a surgically constructed silo (0 versus 77%), wound complications (0 versus 23%), duration of total parenteral nutrition (18.7 versus 34.7 days), time to full enteral feeding (19.1 versus 35.1 days), and hospital discharge (22.7 versus 37.7 days). Elective preterm delivery using specific ultrasound criteria resulted in improved surgical outcome without significant morbidity secondary to prematurity.

The significance of intrauterine growth restriction is different from prematurity for the outcome of infants with gastroschisis

Article

Aug 2004
J PEDIATR SURG

Recent reviews of gastroschisis identify prematurity and low birth weight as predictors of morbidity and mortality. The authors compared the outcomes of intrauterine growth-restricted infants (IUGR) with gastroschisis to those without growth restriction because IUGR is different from prematurity. A retrospective analysis was performed for infants born with gastroschisis between 1990 and 2000 at 2 pediatric hospitals. Patients were segregated into 3 groups based on birth weight corrected for gestational age: group 1 (IUGR, <fifth percentile), group 2 (fifth to 25th percentile), and group 3 (>25th percentile). Patient demographics, method of closure, number of surgeries, presence of atresia, and time to full enteral feedings (FPO days) were assessed. Mortality rate, length of stay (LOS), and readmission rates were also compared. Analysis of variance (ANOVA)/Student's t test and Fisher's. Exact tests were used for statistical analysis (P <.05 significant). Regression analysis was also performed. One hundred thirteen patients were included (group 1 = 17; group 2 = 43; group 3 = 53). Overall, infants with IUGR had similar outcomes to non-IUGR infants, including FPO and total parenteral nutrition (TPN) days, LOS, readmission, and mortality rates. The method of closure did not affect outcome. Infants with atresia had significantly increased times to full feeding (95 v 34 days; P =.034), more surgeries (2.7 v 1.4; P =.002), and longer LOS (106 v 48 days; P =.011). Infants born at less than 37 weeks' gestation had significantly increased fasting (NPO) days (28 v 18 days; P =.005) and longer LOS (65 v 37 days; P =.006) when compared with infants born at greater than 37 weeks. Logistic regression analysis identified the presence of atresia as an independent risk factor for gastrointestinal dysfunction and the need for prolonged TPN. Prematurity also adversely affected these same parameters, although it did not reach statistical significance. Although infants with gastroschisis are generally small for gestational age, the outcomes of growth-restricted infants are similar to those of other infants. The type of closure does not affect outcome, regardless of birth weight. The presence of atresia or prematurity does lead to longer times for full feeding and LOS. Therefore, routine premature delivery of infants with gastroschisis should not be advocated, even in the context of IUGR.

Mode of Delivery and Neonatal Survival of Infants With Isolated Gastroschisis

Article

Nov 2004
OBSTET GYNECOL

We sought to compare neonatal survival of infants with gastroschisis by mode of delivery. We conducted a retrospective cohort study on infants with gastroschisis who were delivered in New York State from 1983 through 1999. We compared neonatal mortality between infants born vaginally and those delivered by cesarean using adjusted hazard ratios derived from Cox proportional hazards regression models. A total of 354 infants were found to have isolated gastroschisis. Of these, 174 were delivered vaginally, whereas 180 were delivered by cesarean. Neonatal mortality was registered among 18 infants (5.1%); 12 (6.9%) in the vaginal and 6 (3.3%) in the cesarean group. After controlling for potential confounders, the risk for neonatal demise was similar in both the vaginal and cesarean subcohorts (adjusted hazard ratio 0.84, 95% confidence interval [CI] 0.29-2.43). Preterm birth was the morbidity pathway that explained the early demise of infants with gastroschisis, irrespective of mode of delivery (adjusted hazard ratio 3.4, 95% CI 1.10-10.4) whereas small for gestational age did not predict mortality (adjusted hazard ratio 1.04, 95% CI 0.13-8.14). In this study the mode of delivery was not found to be associated with neonatal survival of infants with gastroschisis. Preterm birth rather than small for gestational age was the predictor of neonatal death among gastroschisis infants. III

The timing of delivery of infants with gastroschisis influences outcome

Article

Mar 2005
J PEDIATR SURG

The delayed onset of intestinal function in children with gastroschisis may be because of the injurious effects of amniotic fluid on the exposed bowel. This has led to consideration of early delivery to minimize intestinal damage and improve outcome, although this has not been carefully evaluated. The authors hypothesized that timing of delivery influences outcome in children with gastroschisis, and sought to evaluate the relative impact of factors that predict outcome in this disease. All consecutive patients with gastroschisis (1992-2002) were divided into those delivered before ("early") or after ("late") 36 weeks. Bowel peel was described as "thin" or "thick," based on operative reports. Individual measures were analyzed by univariate analyses (chi2 /Student's t test), and logistic regression was used to identify significant factors for the length of stay (LOS) longer than the population average of 55 days. In 75 patients, 53.4% were "early" and 46.6% were "late." Groups were similar with respect to maternal age, birth weight, delivery mode, sex, and associated anomalies. Thickness of bowel peel was not affected by delivery time, yet "early" patients had significantly longer LOS and time to enteral feeds. Significant predictors of LOS more than 55 days included gestational age of 36 weeks or younger, time to enteral feeds of more than 26 days, and associated anomalies. Nonsignificant predictors included size of the defect, thickness of bowel peel, and need for silo. Delivery before 36 weeks is associated with longer hospitalization and increased tune to attainment of full feeds compared with later delivery. Fetal well-being should thus be the primary determinant of delivery for gastroschisis, as opposed to considerations regarding possible injurious effects to the bowel of prolonged gestation.

A randomized controlled trial of elective preterm delivery of fetuses with gastroschisis

Article

Dec 2005
J PEDIATR SURG

Elective preterm delivery of the fetus with gastroschisis may help to limit injury to the extruded fetal gut and thus promote faster recovery of neonatal gut function and earlier hospital discharge. This hypothesis has not previously been tested in a prospective randomized controlled trial. Between May 1995 and September 1999, all women referred to a single tertiary center before 34 weeks' gestation with a sonographically diagnosed fetal gastroschisis were invited to participate in a randomized controlled trial. Eligible patients were randomized to elective delivery at 36 weeks or to await the onset of spontaneous labor. The method of delivery was not prescribed by the trial. Primary outcome measures in the neonate were the time taken to tolerate full enteral feeding (150 mL/kg per day) and duration of hospital stay. Of 44 eligible women, 42 were randomized, 21 to elective delivery and 21 to await spontaneous labor. There were 20 liveborn infants in each group. Four babies in the elective group and 4 in the spontaneous group delivered before 36 weeks' gestation but were included in the analysis on an intention-to-treat basis. Mean gestational age at delivery was 35.8 weeks in the elective group and 36.7 weeks in the spontaneous group. Primary closure of the gastroschisis was achieved in a similar proportion (80%-85%) of infants in both groups. Two babies in the elective group died from short gut complications. In the survivors, there was a trend in favor of a shorter median time to achieve full enteral feeding (30.5 vs 37.5 days) and a shorter median duration of hospital stay (47.5 vs 53 days) in the elective group, but this was not statistically significant. These findings remained unaltered when the data were reanalyzed after (a) excluding infants with intestinal atresia or (b) excluding infants born before 36 weeks' gestation. Although limited by the small number of patients, this randomized controlled trial demonstrates no significant benefit from elective preterm delivery of fetuses with gastroschisis.

The incidence of gastroschisis - Research urgently needs resources

Article

Mar 2006
Br Med J

EDITOR—Kilby says that gastroschisis shows an increasing temporal trend in the number of affected babies born in the United Kingdom,1 a trend that has also been observed in other parts of the world.2 We evaluated the data of 25 registries of members of the International Clearinghouse for Birth Defects …

Outcome of gastroschisis: A 20-year case review of infants with gastroschisis born in Galveston, Texas

Article

Jun 2006
J PEDIATR SURG

In the past decade, the preferred method of closure of gastroschisis at our institution has been staged reduction using a silo with repair on an elective basis (SR) rather than primary surgical closure (PC). We performed a 20-year case review of infants with gastroschisis at a university hospital to compare these shifts in management and to determine factors affecting outcome. Seventy-two cases were reviewed from 1983 to 2003. Times to first and full feeds were outcome variables for statistical analysis. The prevalence of gastroschisis increased from 0.03% to 0.1% since 1983. Patients had low birth weights (mean = 2294 g) and were borderline premature (mean = 35.8 weeks). Only 3% of the infants were African American. There was a high rate of cesarean deliveries (57%). Ten patients (15%) had gastroschisis complicated by liver herniation, intestinal atresia(s), and/or necrosis/perforation. Most patients were managed by SR (67%). Eight percent of the infants died, 9% developed necrotizing enterocolitis, and 50% had other gastrointestinal complications. Twenty-seven percent of the infants managed with SR did not need initial mechanical ventilation. However, the patients who underwent SR were ventilated longer after birth as compared with those who underwent PC (P < .08). Infants with a complicated gastroschisis had significantly longer times to first and full feeds (P < .001). Patients managed with SR took significantly longer to reach full feeds (P = .001), and there was a trend of starting feeds later (P = .06). When patients with a complicated gastroschisis were excluded, the differences between the SR and PC groups were even greater (P = .01; P < .001). In our patient population, the prevalence of gastroschisis increased by more than 400% since 1983. The defect was rare in African-American infants. Management by SR was associated with longer ventilation times and longer times to first and full feeds for both uncomplicated and complicated gastroschisis cases.

Biochemical Investigations of Bowel Inflammation in Gastroschisis

Article

Dec 2006

Neonates with gastroschisis have perivisceritis resulting from contact between the bowel and amniotic fluid. Here, we characterized the mediators involved in this inflammatory process in humans and ewes, to find a reliable marker of this process. We have diagnosed 41 cases of gastroschisis since 1995. Amniotic fluid sampled for karyotyping between 15 and 32 wk of gestation was also used to assay cytokines and inflammatory proteins. The findings were compared with those in 93 age-matched controls. Amniotic fluid cells were analyzed by means of cytology. Histologic examination of the bowel was performed when neonatal appendectomy was performed. The findings were compared with those obtained in a ewe model of gastroschisis. In gastroschisis, amniotic total protein, IL-6, IL-8, and ferritin levels were significantly higher than in controls. Gastroschisis was associated with significantly higher cell counts (mainly mononuclear cells) in amniotic fluid. At birth, macrophages were abundant in the fibrous peel covering the bowel. Similar results were obtained in the ewe model. Gastroschisis may be associated with a subchronic inflammatory process of variable intensity. This inflammation is restricted to the bowel wall and involves inflammatory cells such as macrophages, which may secrete ferritin, neopterin, and calprotectin.

Postnatal outcome in gastroschisis: Effect of birth weight and gestational age

Article

May 2007
J PEDIATR SURG

Early elective delivery of antenatally diagnosed gastroschisis has been proposed as a strategy to minimize postnatal morbidity. This hypothesis was tested by analyzing outcome in relationship to gestational age and birth weight at delivery. Single-center retrospective review of infants born with gastroschisis over a 13-year period (January 1993-December 2005). Standard outcome measures were compared using nonparametric methods. Data are quoted as median values (range). The study population consisted of 110 infants with gastroschisis. They were divided according to gestational age (group A, <35 weeks; group B, 35-37 weeks; group C, >37 weeks) and birth weight (group D, <2 kg; group E, 2-2.5 kg; group F, >2.5 kg). Duration in hospital (P < .01) and time to full enteral feeding (P = .05) was increased in group A vs groups B and C. In comparison, duration in hospital (P < .01), days ventilated (P = .03), establishment of full feeds (P = .01), and parenteral nutrition (P = .02) were all prolonged in group D vs groups E and F. Six (5%) infants died (group D, n = 3; group E, n = 3). Necrotizing enterocolitis was found in 7 infants, and confined to groups D and E (chi2 for trend P = .06). There is no evidence that prematurity confers an advantage in restitution of gastrointestinal function in infants with gastroschisis; indeed, the opposite appears true. Birth weight, rather than gestational age, appears a better predictor of outcome.

Amnioexchange for fetuses with gastroschisis: is it effective?

Article

Jun 2007
J PEDIATR SURG

Amniotic fluid of fetuses with gastroschisis (GS) contains inflammatory mediators, gastrointestinal, and urinary waste products. Dilution and removal of such harmful substances have been advocated to prevent damage to the herniated intestine. We evaluated the effectiveness of serial amnioexchange procedures in 8 consecutive fetuses with GS. Amnioexchange was performed bimonthly during the third trimester. Amniotic fluid collected before each procedure was tested for pH, osmolarity, urea, creatinine, cystatin-C, proteins, albumin, bilirubin, biliary salts, pancreatic amylase, serum amyloid A, C-reactive protein, alanine transaminase (ALT), alcaline phosphatase (ALP), gamma-glutamyl transpetidase (gammaGT), tumor necrosis factor alpha, interleukin 2, interleukin 6, epidermal growth factor, transforming growth factor beta, and myeloperoxidase. A total of 25 samples (median, 3 per fetus) were examined. Biochemical or inflammatory markers did not correlate with gestational age, nor was any trend observed in values from individual patients during the course of amnioexchange treatment. There was no correlation between biochemical or inflammatory markers and clinical outcome, including time to full enteral feeding. Serial amnioexchanges did not modify the biochemical or inflammatory status of amniotic fluid nor appeared to prevent injury to the herniated gut. Because repeated amnioexchanges may carry some risks, their use in fetuses with GS is not recommended outside the setting of a prospective randomized trial.

Gastroschisis: Growth Patterns and a Proposed Prenatal Surveillance Protocol

Article

Feb 2007
FETAL DIAGN THER

To assess intrauterine growth for fetuses with gastroschisis using retrospective serial ultrasound assessment from fetuses diagnosed prenatally with gastroschisis. The growth assessment could be available as a prospective tool to direct an antepartum fetal surveillance protocol. This is a retrospective review of all cases of gastroschisis evaluated prenatally at a single institution between February 1996 and March 2002. Charts were reviewed for serial ultrasound assessment, gestational age at delivery, mode of delivery, and birth weight. Growth assessment was determined for abdominal circumference, biparietal diameter, head circumference, femur length, and estimated fetal weight (IRB No. 2002-1-2648). Forty patients had delivered by March 2002. One hundred and two ultrasound reports were reviewed. Gastroschisis growth curves showed that the 50th percentile was shifted to the right when compared to normal growth curves for abdominal circumference, biparietal diameter, head circumference, and femur length. The average birth weight was 2,359 g. Compared with a standard population, 44% (16/36) were below the 5th percentile, 61% (22/36) were below the 10th percentile, and 95% (34/36) were below the 50th percentile for gestational age. The average gestational age at delivery was 36.3 weeks. Mothers were nulliparous in 78%, with a mean age of 21.3 years. (1) Fetuses with gastroschisis show a symmetric intrauterine growth restriction pattern consistent with early development of growth delay; (2) the 50th percentile biometry measurements for the gastroschisis population are shifted to the right on normal fetal growth curves; (3) the birth weight is at or below the 10th percentile in 61% of the newborns with gastroschisis, and (4) an antepartum surveillance protocol is proposed based on growth patterns of fetuses with gastroschisis.

Outcomes of Pregnancies With Fetal Gastroschisis

Article

Oct 2007
OBSTET GYNECOL

To describe pregnancy outcomes with fetal gastroschisis, including the associations of prenatal ultrasound findings with neonatal surgical complications and other morbidities. This was a review of pregnancies complicated by fetal gastroschisis and delivered from January 1998 through June 2006. The last ultrasonogram before delivery was reviewed to determine stomach dilatation, bowel dilatation, or abnormalities of amniotic fluid volume. Neonatal records were reviewed to determine type of closure and any bowel complications. There were 66 pregnancies with gastroschisis, 1 per 2,000 deliveries. There were three stillbirths and three neonatal deaths. Delayed closure was necessary in 49% who underwent surgery. Birth weight below the third percentile, which occurred in 38%, was associated with need for delayed closure, 64% compared with 25% without growth restriction, P<.001, but was not associated with longer hospital stay or neonatal death. Fetal gastroschisis was diagnosed by prenatal ultrasonography in 58 cases. Bowel complications requiring surgery were more frequent when ultrasonography had demonstrated stomach dilatation (five cases), 60% compared with 10%, P=.002. Fetuses with defects so large that no normal ventral wall could be visualized ultrasonographically (three cases) were at increased risk for neonatal death, 100% compared with 0%, P<.001. Ultrasound findings associated with adverse outcome in fetal gastroschisis included stomach dilatation and a defect so large that no normal ventral wall could be visualized. Fetal growth restriction was common, and such infants were more likely to require delayed gastroschisis closure. Despite more than 90% survival, morbidity with gastroschisis remains high. II.

Gastroschisis: what is the average gestational age of spontaneous delivery?

Article

Nov 2007
J PEDIATR SURG

To consolidate what is known about pregnancies complicated by fetal gastroschisis through analysis of one of the largest series yet reported and to define the average gestational age of spontaneous delivery. From 1980 to 2001, 159 pregnancies complicated by fetal gastroschisis were identified at a tertiary care center. Gestational age at delivery, birth weight, preterm delivery rate, and maternal age were compared to the 2001 general population statistics. Patients with pregnancies complicated by gastroschisis who went into spontaneous labor (n = 86) were subdivided into 2 groups based on gestational age (< 37 weeks and > or = 37 weeks). Operative delivery rates for nonreassuring fetal status and Apgar scores were assessed. Gastroschisis occurred more often in younger mothers (< 21 years) (42% vs 7.3%), was more frequently associated with preterm labor and delivery (28% vs 6%), and was associated with more low-birth-weight babies (36% vs 10%). The mean gestational age at spontaneous labor was 36.6 weeks. In those patients who labored spontaneously, there were no significant differences in the operative delivery rates for fetal distress; however, there was a trend to lower Apgar scores in babies born at 37 weeks or more. Our data provide a framework for further studies to determine the optimal timing and mode of delivery for fetuses with gastroschisis.

The outcome of gastroschisis after a prenatal diagnosis or a diagnosis only at birth - Recommendations for prenatal surveillance

Article

Aug 2008
EUR J OBSTET GYN R B

To establish in infants with gastroschisis whether outcome is different when comparing a prenatal diagnosis with a diagnosis only at birth with the intention to develop a prenatal surveillance protocol. Intestinal atresia established after birth and preterm versus term delivery were studied as risk factors. All 24 fetuses and 9 infants diagnosed with gastroschisis and referred to our tertiary center between January 1991 and June 2003 were studied retrospectively. The infants of the prenatal subset delivered at our tertiary center and 18 survived. There were two pregnancy terminations, three intrauterine deaths at 19, 33 and 36 weeks respectively and one neonatal death. All nine infants in the postnatal subset survived. Eight were out born and one was delivered at our tertiary center. Prenatal bowel dilatation did not correlate with outcome. Between the prenatal and postnatal subset no significant difference in outcome of live-born infants was established. For four infants with intestinal atresia a significant difference was demonstrated for induction of preterm labour (P<0.05), duration of parenteral nutrition (P<0.01), number of additional surgical procedures (P<0.001) and length of hospital stay (P<0.01). The fifteen infants born prior to 37 weeks of gestation spent a significantly longer period in hospital compared to those delivered at term. When the cases with bowel atresia were excluded this difference was no longer present. Five of the 33 cases were diagnosed with associated anomalies which mainly involved the urinary tract. Neonatal outcome of live born infants following a prenatal diagnosis of gastroschisis is not different from a diagnosis at birth. The presence of intestinal atresia is the most important prognostic factor for morbidity. The supplemental value of prenatal diagnosis to the outcome of infants with gastroschisis may be in the prevention of unnecessary intrauterine death and detection of intestinal complications. A proposed surveillance protocol for fetuses with gastroschisis focused on intrauterine signs of pending distress such as a dilated stomach, intra abdominal bowel dilatation with peristalsis, notches in the umbilical artery Doppler signal, development of polyhydramnios and an abnormal CTG registration may improve outcome.

Preliminary Report on Elective Preterm Delivery at 34 Weeks and Primary Abdominal Closure for the Management of Gastroschisis

Article

Mar 2008

We aimed to critically evaluate elective preterm delivery and immediate abdominal wall closure and other techniques for the management of gastroschisis, hypothesizing that the advantages of an elective preterm delivery outweigh possible complications related to prematurity at birth. 13 gastroschisis patients were enrolled in the elective preterm delivery program (Group 1) since 1999. Patients were delivered by cesarean section in the 34th gestational week, with immediate primary closure of the defect. Data regarding parameters at and after birth were compared with a historical control group of 10 patients conventionally managed for gastroschisis in a similar period (1994 - 1999) (Group 2). The primary endpoints of this study were the initiation of oral feeding and the length of hospital stay. There was a significantly faster initiation of oral feeding (p = 0.0012) and a shorter hospital stay (p = 0.0160) in Group 1. The postoperative outcome was excellent in all patients. Acute and late complications were fewer and less severe in Group 1 and none were related to prematurity. Elective preterm delivery appears to be an effective method for the management of gastroschisis, and a method whose advantages thus far have outweighed the possible complications due to prematurity.

Gastroschisis: The cost of an epidemic

Article

May 2008
J PEDIATR SURG

The rising incidence of gastroschisis has been highlighted by the Department of Health as a growing concern. As well as the health implications for the increasing number of affected infants, this increase in incidence will have an impact of the costs of health care. This study was undertaken to estimate the financial cost of treating this condition in one tertiary neonatal surgical center. A retrospective analysis was performed of all patients admitted to a tertiary neonatal surgical center with gastroschisis from January 1996 to December 2005. The main outcome measures were incidence, length of hospital stay, and total cost for all patients each year. The incidence of gastroschisis has risen 3-fold in 10 years. The median cost per patient is relatively constant. A few patients with severe intestinal dysmotility require prolonged hospital stay. As the condition becomes more common, there are an increasing number of complex patients and thus an increase in annual costs, which is disproportionate to the increase in numbers of cases. We estimate that the annual cost to the National Health Service (NHS) of this condition in England and Wales has risen from pound3.6 million in 1996 to in excess of pound15 million in 2005. Urgent research is required into the etiology of gastroschisis and into the severe intestinal dysmotility that occurs in some complex patients.

Expectant Management Compared With Elective Delivery at 37 Weeks for Gastroschisis

Abstract

No full-text available

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