Gastroschisis: International epidemiology and public health perspectives

Prevalence and correlates of gastroschisis in 15 states, 1995 to 2005

OBJECTIVE

To identify trends in the prevalence and epidemiologic correlates of gastroschisis using a large population-based sample with cases identified by the National Birth Defects Prevention Network over the course of an 11-year period.

METHODS

This study examined 4,713 cases of gastroschisis occurring in 15 states during 1995-2005, using public use natality data sets for denominators. Multivariable Poisson regression was used to identify statistically significant risk factors, and Joinpoint regression analyses were conducted to assess temporal trends in gastroschisis prevalence by maternal age and race and ethnicity.

RESULTS

Results show an increasing temporal trend for gastroschisis (from 2.32 per 10,000 to 4.42 per 10,000 live births). Increasing prevalence of gastroschisis has occurred primarily among younger mothers (11.45 per 10,000 live births among mothers younger than age 20 years compared with 5.35 per 10,000 among women aged 20 to 24 years). In the multivariable analysis, using non-Hispanic whites as the referent group, non-Hispanic black women had the lowest risk of having a gastroschisis-affected pregnancy (prevalence ratio 0.42, 95% confidence interval [CI] 0.37-0.48), followed by Hispanics (prevalence ratio 0.86, 95% CI 0.81-0.92). Gastroschisis prevalence did not differ by newborn sex.

CONCLUSIONS

Our findings demonstrate that the prevalence of gastroschisis has been increasing since 1995 among 15 states in the United States, and that higher rates of gastroschisis are associated with non-Hispanic white maternal race and ethnicity, and maternal age younger than 25 years (particularly younger than 20 years of age).

LEVEL OF EVIDENCE

III.

Violence against women and gastroschisis: a case-control study

BACKGROUND

Gastroschisis, a birth defect characterized by herniated fetal abdominal wall, occurs more commonly in infants born to teenage and young mothers. Ischemia of the vascular vitelline vessels is the likely mechanism of pathogenesis. Given that chronic stress and violence against women are risk factors for cardiovascular disease we explored whether these may represent risk factors for gastroschisis, when they occur during pregnancy. A case-control study was conducted, with 15 incident cases of children born with gastroschisis in the Region of Murcia, Spain, from December 2007 to June 2013. Forty concurrent controls were recruited at gestation weeks 20-24 or post-partum. All mothers of cases and controls completed a comprehensive, in-person, 'green sheet' questionnaire on environmental exposures.

RESULTS

Mothers of children with gastroschisis were younger, smoked more cigarettes per week relative to controls, were exposed to higher amounts of illegal drugs, and suffered from domestic violence more frequently than the controls. Multivariable logistic regression analysis highlights periconceptional 'gender-related violence' (OR: 16.6, 95% CI 2.7 to 101.7) and younger maternal age (OR 1.1, 95% CI 1.0-1.3).

CONCLUSIONS

Violence against pregnant women is associated with birth defects, and should be studied in more depth as a cause-effect teratogenic. Psychosocial risk factors, including gender-based violence, are important for insuring the health and safety of the pregnant mother and the fetus.

Metaanalysis of the prevalence of intrauterine fetal death in gastroschisis

OBJECTIVE

The objective of this study was to review the medical literature that has reported the risk for intrauterine fetal death (IUFD) in pregnancies with gastroschisis.

STUDY DESIGN

We systematically searched the literature to identify all published studies of IUFD and gastroschisis through June 2011 that were archived in MEDLINE, PubMed, or referenced in published manuscripts. The MESH terms gastroschisis or abdominal wall defect were used.

RESULTS

Fifty-four articles were included in the metaanalysis. There were 3276 pregnancies in the study and a pooled prevalence of IUFD of 4.48 per 100. Those articles that included gestational age of IUFD had a pooled prevalence of IUFD of 1.28 per 100 births at ≥36 weeks' gestation. The prevalence did not appear to increase at >35 weeks' gestation.

CONCLUSION

The overall incidence of IUFD in gastroschisis is much lower than previously reported. The largest risk of IUFD occurs before routine and elective early delivery would be acceptable. Risk for IUFD should not be the primary indication for routine elective preterm delivery in pregnancies that are affected by gastroschisis.

Antiherpetic medication use and the risk of gastroschisis: findings from the National Birth Defects Prevention Study, 1997-2007

BACKGROUND

Previous studies examining the teratogenic effects of antiherpetic medications have found no associations for birth defects overall but have not examined the risk of specific birth defects.

METHODS

The National Birth Defects Prevention Study ascertains population-based cases with birth defects and live-born controls without birth defects in 10 states across the United States for the purpose of identifying potential teratogenic risk factors. Mothers of cases and controls are interviewed within 2 years of their estimated date of delivery about demographic, medical and behavioural factors before and during pregnancy. This analysis examined the possible association between use of antiherpetic medications (acyclovir, valacyclovir or famciclovir) during early pregnancy and gastroschisis, a birth defect of the abdominal wall.

RESULTS

The mothers of 1.1% (n = 10) of 941 gastroschisis cases and 0.3% (n = 27) of 8339 controls reported antiherpetic medication use during the month before conception through the third month of pregnancy. The adjusted odds ratios for such use in relation to gastroschisis were 4.7 [95% confidence interval 1.7, 13.3] and 4.7 [95% CI 1.2, 19.0] among women with and without self-reported genital herpes, respectively, when compared with women without antiherpetic use or herpes. Among women reporting no antiherpetic medication use, the odds ratio for self-reported genital herpes in relation to gastroschisis was 3.0 [95% CI 1.6, 5.7].

CONCLUSIONS

Our study raises the possibility of an increased risk of gastroschisis because of either antiherpetic medication use during early pregnancy or the underlying genital herpes infection for which it was indicated.

Birth region, race and sex may affect the prevalence of congenital diaphragmatic hernia, abdominal wall and neural tube defects among US newborns

OBJECTIVE

Birth defects are number one cause of death among infants below 1 year of age. The objective is to examine the interaction of sex, race/ethnicity and place of birth on the prevalence of major congenital birth anomalies.

STUDY DESIGN

We analyzed the data sets produced by the Healthcare Cost and Utilization Project (HCUP) for the years 1997-2004. We identified the malformations: congenital diaphragmatic hernia (CDH), abdominal wall defects (AWD) and neural tube defects (NTD) using their respective International Classification of Disease 9 diagnostic codes. Newborns were classified according to their birth region into four groups; Northeast, South, Midwest and West. We calculated prevalence of each disease for the overall sample then for every sex, race and birth region. Using stratified analysis and χ(2) test, we calculated the odds ratio (OR) risk for each disease comparing females with males, different races/ethnicity to Caucasians and different US regions to Northeast.

RESULT

There were 1291 newborns with CDH representing 0.031% of the sample. (AWD: 2184 (0.052%) and NTD: 979 (0.024%)). West region had the highest prevalence of CDH (OR=1.62 (confidence intervals (CI): 1.4-1.9, P<0.001)). Female-to-male risk disparities were most observed among Caucasians in the South (OR=1.44 (CI: 1.1-1.8, P=0.003)). African Americans had the least prevalence of CDH but only in the South (OR=0.67 (CI: 0.5-0.8, P=0.001)). Native Americans had higher risk for AWD in the Midwest and West regions compared with Caucasians.

CONCLUSION

This study links the birth region as a detrimental factor like sex and race in the prevalence of CDH, AWD and NTD. These findings implicate a possible role for environmental factors in the pathogenesis of these diseases.

The role of maternal nutrition in the aetiology of gastroschisis: an incident case-control study

BACKGROUND

Gastroschisis, a congenital anomaly involving a defect in the fetal abdominal wall, has increased in prevalence in many countries, but the aetiology is uncertain. We tested the hypothesis that high maternal alcohol consumption and poor diet in the first trimester are risk factors in a case-control study in the UK (1 July 2007 to 28 February 2010).

METHODS

Gastroschisis cases and three controls per case (matched for maternal age) were identified at 18- to 20-week routine anomaly screening ultrasound scan (USS). Interviews were carried out during the antenatal period (median 24 weeks' gestation) using a piloted questionnaire. Conditional logistic regression was used to describe the associations between exposure variables and gastroschisis, adjusted for known confounding variables.

RESULTS

The response rate was 73% for cases (n = 91) and 70% for controls (n = 217). High consumption of fruits and vegetables during the first trimester (aOR 0.2; 95% CI 0.04-0.6), taking folic acid for at least 6 weeks during the first trimester (aOR 0.3; 95% CI 0.1-0.7) and increasing body fat percentage of total maternal body weight (aOR 0.9; 95% CI 0.8-0.9 per 1% increase) were independently associated with reduced risk. Cigarette smoking (aOR 2.7; 95% CI 1.1-6.8) was an independent risk factor.

CONCLUSION

We report for the first time that higher intake of fruits and vegetables during the first trimester, longer duration of folic acid supplementation and higher body fat percentage are associated with reduced risk of fetal gastroschisis, independent of cigarette smoking. The increased risk of cigarette smoking is greatest in older women and in high socio-economic groups.

The omega-6 fatty acid linoleic acid is associated with risk of gastroschisis: a novel dietary risk factor

Gastroschisis is a congenital abdominal wall defect, thought by many to represent a disruption in intrauterine blood flow, where there is herniation of abdominal organs. Dietary intake is an important environmental factor that has been implicated in the development of many diseases. Omega-6 polyunsaturated fatty acids (PUFAs) are nutrients that are substrates for eicosanoid and cytokine synthesis and prone to oxidation, and play a role in modulating inflammation, immune function, and vascular system development. This pilot case-control study explored the association of dietary intake of the omega-6 PUFA linoleic acid with risk of gastroschisis. Between 2008 and 2011, we recruited 13 pregnant women in mid-gestation who were referred to the UCSD Prenatal Center for evaluation of an abnormal alpha-fetoprotein (AFP) test and subsequently identified as carrying a baby with gastroschisis. Nine controls were selected from a false positive AFP or from the UCSD prenatal clinic. Maternal dietary intake was collected via repeated food record during the last 20 weeks of gestation. Logistic regression was used to test the association between dietary intake of linoleic acid and odds of gastroschisis. Dietary intake of linoleic acid was associated with increased odds of gastroschisis (OR = 1.72; 95% CI: 1.08, 2.74; P = 0.02). A higher maternal intake of omega-6 PUFAs may increase the risk of having a baby with gastroschisis. The mechanism by which this occurs may be via inflammatory processes and oxidative stress leading to a vascular disruption. More research is needed including studies investigating integrated markers of PUFA status or inflammatory markers.

Neonatal abdominal wall defects

Gastroschisis and omphalocele are the two most common congenital abdominal wall defects. Both are frequently detected prenatally due to routine maternal serum screening and fetal ultrasound. Prenatal diagnosis may influence timing, mode and location of delivery. Prognosis for gastroschisis is primarily determined by the degree of bowel injury, whereas prognosis for omphalocele is related to the number and severity of associated anomalies. The surgical management of both conditions consists of closure of the abdominal wall defect, while minimizing the risk of injury to the abdominal viscera either through direct trauma or due to increased intra-abdominal pressure. Options include primary closure or a variety of staged approaches. Long-term outcome is favorable in most cases; however, significant associated anomalies (in the case of omphalocele) or intestinal dysfunction (in the case of gastroschisis) may result in morbidity and mortality.

Maternal nutrition and gastroschisis: findings from the National Birth Defects Prevention Study

OBJECTIVE

Gastroschisis is increasing in many countries, especially among young women. Because young women may have inadequate nutrition, we assessed the relationship between individual nutrients and the risk for gastroschisis.

STUDY DESIGN

We analyzed data from the National Birth Defects Prevention Study, a population-based case-control study. Cases were ascertained from 10 birth defect surveillance systems. Controls were randomly selected from birth certificates or hospital records. Nutrient intake was estimated for the year prior to conception from maternal interviews based on a 58-item food frequency questionnaire and cereal consumption reported. A total of 694 cases and 6157 controls were available for analysis.

RESULTS

Reported intake of individual nutrients did not substantially affect the risk for gastroschisis. Stratification by maternal age, preconception body mass index, folic acid-containing supplements, or energy intake (kilocalories) did not alter risk estimates.

CONCLUSION

This study does not support an increased risk for gastroschisis with decreasing tertiles of individual nutrients.

Assessing the trend of gastroschisis prevalence in China from 1996 to 2007 using two analytical methods

BACKGROUND

In recent years, the prevalence of gastroschisis has increased remarkably in some areas and remained unchanged in other areas; however, in general, there is a recent increasing trend compared to the 1970s and 1980s. In this study, we explored the time trend of gastroschisis prevalence in China during 1996 to 2007.

METHODS

Data were retrieved from the hospital-based national monitoring database maintained by the Chinese Birth Defects Monitoring Network (CBDMN). The monitored subjects were infants born on the 28th gestational week or later, including live births and stillbirths. The maximal time for the diagnosis of a congenital malformation was the seventh day after birth. The secular trends on the overall prevalence and the different feature-specific prevalence of gastroschisis in China were analyzed using the linear chi-square test and the Poisson regression model.

RESULTS

The overall prevalence of gastroschisis in China was 2.54 per 10,000 births during 1996 to 2007. Except for the prevalence of gastroschisis that significantly increased among infants whose mothers were 20 to 24 years old (p=0.0498 for the linear chi-square test, p=0.0032 for the Poisson regression model analysis) and significantly decreased among infants whose mothers were 30 to 34 years old (p=0.0177 for the Poisson regression model analysis), no significant changes were found in the overall and remaining feature-specific prevalences.

CONCLUSION

The overall prevalence of gastroschisis in China did not change remarkably during 1996 to 2007; but the prevalence of gastroschisis significantly increased among infants whose mothers were 20 to 24 years old and decreased among infants whose mothers were 30 to 34 years old.

Preterm elective caesarean section and early enteral feeding in gastroschisis

AIMS

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Perinatal demography of gastroschisis in North Queensland

AIM

To review the demography of gastroschisis in North Queensland.

METHODS

A retrospective chart review of live born cases of gastroschisis originating in North Queensland from 1988 to 2007.

RESULTS

Fifty-nine cases were identified, giving an overall rate of 3.2 per 10,000 live births. In mothers <20 years old compared with 20-24 and 25-29 it was 12.1, 6.3 and 1.7. Overall, the rate was higher in Indigenous mothers (6.6 vs. 2.6, OR 2.5; 95% CI 1.4-4.5, P= 0.0018). Overall, the rate increased significantly from 0.7 per 10,000 live births in the first 5 years of the study to 4.8 in the last (trend test P= 0.0015), but it increased particularly in mothers <20 years old, from 2.40 in the first 5 years to 19.3 in the last (trend test P= 0.0177). It also rose from 0 to 3.6 in those aged 25-29 (P= 0.0337) but remained stable in other age groups. There was no difference in the outcomes of babies born to Indigenous or non-Indigenous mothers, or in outcomes of babies delivered vaginally or by Caesarean section, or in outcomes of babies from any particular location in North Queensland. There was no significant difference in the average age of Indigenous and non-Indigenous mothers.

CONCLUSION

Gastroschisis is increasing in North Queensland, especially in mothers <20. Overall, the rate in Indigenous mothers is two to three times higher.

Familial recurrence of gastroschisis: literature review and data from the population-based birth registry "Mainz Model"

BACKGROUND

Familial forms of gastroschisis are considered rare. A search for these forms in a population-based birth registry in 1993 found a recurrence risk of 3.5% among first-degree relatives. Since then, similar investigations in population-based registries have led to contradictory results.

METHODS

A search of the population-based birth registry "Mainz Model" for familial cases of gastroschisis and a systematic review of the literature were performed.

RESULTS

The Mainz Model database yielded 1 familial recurrence out of 27 gastroschisis cases. From the literature, 37 affected families could be retrieved. Among 412 gastroschises from population-based registries, 10 familial recurrences have been found. These translate into a recurrence risk of 2.4%, with a strong tendency toward underestimation.

CONCLUSION

The existing data support the hypothesis that familial recurrence of gastroschisis is much more likely than previously thought.

Tracing drinking water to its source: An ecological study of the relationship between textile mills and gastroschisis in North Carolina

Gastroschisis is a rare birth defect that has increased in prevalence over the past several decades but the etiology of the disease is largely unknown. Using data from the North Carolina Birth Defects Monitoring Program, we estimated multilevel logistic regression models to evaluate the association between drinking water source and upstream textile mills and the risk of a gastroschisis birth. Results indicate that while prenatal exposure to upstream textile mill effluent does not have an impact on the risk of a gastroschisis birth, women relying on public water systems that draw from a surface water source have an elevated risk. These findings suggest the possibility of a contaminant found in higher levels in surface water compared to groundwater.

Prevalence of gastroschisis and associated hospital time continue to rise in neonates who are admitted for intensive care

PURPOSE

The purpose of this study was to evaluate recent trends in the prevalence of gastroschisis.

METHODS

The study used a retrospective review of a deidentified neonatal intensive care patient data set. To control for ascertainment bias, the prevalence of omphalocele was calculated to provide an internal comparison to another anomaly requiring surgical intervention.

RESULTS

During the study period (1997-2007), there were 473,366 discharges from the neonatal intensive care unit in the data set. There were 2057 (5.3/1000 discharges) neonates who had a gastroschisis and 853 (1.8/1000 discharges) who had an omphalocele. Between 1997 and 2004, the reported rate of gastroschisis increased from 2.9 to 6.1/1000 discharges, a relative increase of 210% (P < .001). Since 2004, the values have remained relatively stable at between 5.5 and 6.2/1000 discharges. Between 1997 and 2007, the hospital days for patients with gastroschisis/total hospital days increased from 0.6% to 1.3%, a relative increase of 220% (P < .001). In contrast, the reported rate of neonates with and the number of hospital days attributed to neonates with omphalocele has not changed significantly.

CONCLUSION

The prevalence and the number of hospital days needed to care for neonates with gastroschisis have continued to increase since 2001.

Risk factors for gastroschisis

Genitourinary infection in early pregnancy can be added to the existing list