Stomach herniation predicts fetal death or non-reassuring fetal status in gastroschisis at late pregnancy

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

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.

Stomach herniation prior to nonreassuring fetal status in a case of fetal gastroschisis

The neonatal prognosis in gastroschisis is generally good; however, intrauterine fetal death (IUFD) and nonreassuring fetal status (NRFS) sometimes occur in fetal cases of gastroschisis. Previously, we reported stomach herniation as a possible risk factor for IUFD or NRFS in fetuses with gastroschisis. We report a case of fetal gastroschisis showing stomach herniation and increased velocity of the umbilical venous (UV) flow the day before NRFS by electronic fetal monitoring (EFM). A 27-year-old pregnant woman was followed up from 16 weeks' gestation due to fetal gastroschisis. At 33 + 1 weeks' gestation, EFM displayed a reassuring fetal state, while the ultrasound examination revealed fetal stomach herniation and an increased flow velocity of the UV in the abdomen. One day later, EFM displayed NRFS, and the patient underwent emergency caesarean section. This case showed stomach herniation preceding the occurrence of NRFS. Stomach herniation may be a predictor of NRFS in fetuses with gastroschisis.

Gastroschisis--what should be told to parents?

Gastroschisis is a common congenital abdominal wall defect. It is almost always diagnosed prenatally thanks to routine maternal serum screening and ultrasound screening programs. In the majority of cases, the condition is isolated (i.e. not associated with chromosomal or other anatomical anomalies). Prenatal diagnosis allows for planning the timing, mode and location of delivery. Controversies persist concerning the optimal antenatal monitoring strategy. Compelling evidence supports elective delivery at 37  weeks' gestation in a tertiary pediatric center. Cesarean section should be reserved for routine obstetrical indications. Prognosis of infants with gastroschisis is primarily determined by the degree of bowel injury, which is difficult to assess antenatally. Prenatal counseling usually addresses gastroschisis issues. However, parental concerns are mainly focused on long-term postnatal outcomes including gastrointestinal function and neurodevelopment. Although infants born with gastroschisis often endure a difficult neonatal course, they experience few long-term complications. This manuscript, which is structured around common parental questions and concerns, reviews the evidence pertaining to the antenatal, neonatal and long-term implications of a fetal gastroschisis diagnosis and is aimed at helping healthcare professionals counsel expecting parents.