Does gastric dilation predict adverse perinatal or surgical outcome in fetuses with gastroschisis?

Gastroschisis ultrasound bowel characteristics demonstrate minimal impact on perinatal outcomes

BACKGROUND

Bowel dilation and bowel wall thickness are common prenatal ultrasound measurements for fetuses with gastroschisis. Data regarding antenatal sonographic bowel findings and postnatal outcomes are conflicting. Our objective was to evaluate the impact of in utero bowel measurements on perinatal outcomes in gastroschisis pregnancies.

METHODS

Retrospective cohort study of 116 pregnancies complicated by gastroschisis between 2011 and 2020. We reviewed ultrasounds documenting fetal bowel measurements. To evaluate the association of these measurements with antepartum and delivery outcomes, we ran logistic and linear models using generalized estimating equations.

RESULTS

Eleven perinatal outcomes reached statistical significance, although with minimal clinical impact given small magnitude of effect. Intra-abdominal bowel dilation was associated with a 0.5 week decrease in delivery gestational age (GA) (95% CI -0.07, -0.03) and a 6.93 g increase in birth weight (95% CI 1.54, 28.73). Intra-abdominal bowel wall thickness was associated with later GA of non-stress test (NST) start of 0.22 weeks (95% CI 0.07, 0.37), increased delivery GA of 0.08 weeks (95% CI 0.02, 0.15), 0.006 decrease in umbilical artery (UA) pH (95% CI -0.009, -0.003), 0.26 increase in UA base deficit (95% CI 0.09, 0.43), and decreased odds of cesarean delivery (OR = 0.83, 95% CI 0.70, 0.99). Extra-abdominal bowel wall thickness was associated with a 0.1 increase in UA base deficit (95% CI 0.02, 0.19) and a 0.05 increase in 5-min APGAR score (95% CI 0.01, 0.09). Stomach cross-section was associated with a 0.01 week decrease in delivery GA (95% CI -0.02, -0.001) and increased odds of receiving betamethasone (OR = 1.02, 95% CI 1.01, 1.04).

CONCLUSIONS

In utero bowel characteristics reached statistical significance for several outcomes, but with minimal meaningful clinical differences in outcomes.

Prenatal ultrasonographic markers for prediction of complex gastroschisis and adverse perinatal outcomes: a systematic review and meta-analysis

OBJECTIVE

We sought to perform a meta-analysis of the predictive value of antenatal ultrasonographic markers of bowel dilation, gastric dilation, polyhydramnios and abdominal circumference that predict complex gastroschisis and adverse perinatal outcomes DATA SOURCES: PubMed, Web of Science, Scopus and Embase were searched for relevant articles up to December 2020. Studies reporting prenatal ultrasonographic markers including intra-abdominal bowel dilation (IABD), extra-abdominal bowel dilation (EABD), bowel wall thickness, polyhydramnios, abdominal circumference <5th percentile, gastric dilation (GD) and bowel dilation not otherwise specified (BD-NOS) were included. The primary outcome was prediction of complex gastroschisis; secondary outcomes were length of hospital stay for newborn, time to full enteral feeding, postnatal mortality rate, incidence of necrotising enterocolitis and short bowel syndrome.

RESULTS

Thirty-six studies were included in this meta-analysis. We found significant associations between complex gastroschisis and IABD (OR=5.42; 95% CI 3.24 to 9.06), EABD (OR=2.27; 95% CI 1.40 to 3.66), BD-NOS (OR=6.27; 95% CI 1.97 to 19.97), GD (OR=1.88; 95% CI 1.22 to 2.92) and polyhydramnios (OR=6.93; 95% CI 3.39 to 14.18). Second trimester IABD and EABD have greater specificity for the prediction of complex gastroschisis than third trimester values with specificity of 95.6% (95% CI 58.1 to 99.7) and 94.6% (95% CI 86.7 to 97.9) for the second trimester IABD and EABD, respectively.

CONCLUSION

Prenatal ultrasonographic markers, especially the second trimester IABD and EABD, can identify fetuses that develop complex gastroschisis. Furthermore, these specific ultrasonographic markers can identify those babies at the highest risk for severe complications of this congenital anomaly and hence selected for future antenatal interventions.

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.

Using three-dimensional ultrasound in predicting complex gastroschisis: A longitudinal, prospective, multicenter cohort study

Objective

To determine whether complex gastroschisis (ie, intestinal atresia, perforation, necrosis, or volvulus) can prenatally be distinguished from simple gastroschisis by fetal stomach volume and stomach‐bladder distance, using three‐dimensional (3D) ultrasound.

Methods

This multicenter prospective cohort study was conducted in the Netherlands between 2010 and 2015. Of seven university medical centers, we included the four centers that performed longitudinal 3D ultrasound measurements at a regular basis. We calculated stomach volumes (n = 223) using Sonography‐based Automated Volume Count. The shortest stomach‐bladder distance (n = 241) was determined using multiplanar visualization of the volume datasets. We used linear mixed modelling to evaluate the effect of gestational age and type of gastroschisis (simple or complex) on fetal stomach volume and stomach‐bladder distance.

Results

We included 79 affected fetuses. Sixty‐six (84%) had been assessed with 3D ultrasound at least once; 64 of these 66 were liveborn, nine (14%) had complex gastroschisis. With advancing gestational age, stomach volume significantly increased, and stomach‐bladder distance decreased (both P < .001). The developmental changes did not differ significantly between fetuses with simple and complex gastroschisis, neither for fetal stomach volume (P = .85), nor for stomach bladder distance (P = .78).

Conclusion

Fetal stomach volume and stomach‐bladder distance, measured during pregnancy using 3D ultrasonography, do not predict complex gastroschisis.

What's already known about this topic?

Infants with complex gastroschisis have a higher risk of morbidity than those with simple gastroschisis.

Many attempts have been made to prenatally predict complex gastroschisis, using two‐dimensional ultrasound parameters.

What does this study add?

This longitudinal prospective multicenter study is the first to evaluate the possible benefit of the use of three‐dimensional ultrasound in fetuses with gastroschisis.

Fetal stomach volume and stomach‐bladder distance, measured during pregnancy using three‐dimensional ultrasound, cannot predict complex gastroschisis.

Examination of Prenatal Sonographic Findings: Intra-Abdominal Bowel Dilation Predicts Poor Gastroschisis Outcomes

BACKGROUND

Gastroschisis is an anterior abdominal wall defect with variable outcomes. There are conflicting data regarding the prognostic value of sonographic findings.

OBJECTIVES

The aim of this study was to identify prenatal ultrasonographic features associated with poor neonatal outcomes.

METHOD

A retrospective review of 55 patients with gastroschisis from 2007 to 2017 was completed. Ultrasounds were reviewed for extra-abdominal intestinal diameter (EAID) and intra-abdominal intestinal diameter (IAID), echogenicity, visceral content within the herniation, amniotic fluid index, defect size, and abdominal circumference (AC). Ultrasound variables were correlated with full enteral feeding and the diagnosis of a complex gastroschisis.

RESULTS

Bivariate analysis demonstrated an increased time to full enteral feeds with increasing number of surgeries, EAID, and IAID. Additionally, there was a significant relationship between IAID and AC percentile with the diagnosis of complex gastroschisis. On multivariate analysis, only IAID was significant and increasing diameter had a 2.82 (95% CI 1.02-7.78) higher odds of a longer time to full enteral feeds and a 1.2 (95% CI 1.05-1.36) greater odds of the diagnosis of a complex gastroschisis.

CONCLUSIONS

Based on these findings, IAID is associated with a longer time to full enteral feeding and the diagnosis of complex gastroschisis.

Complex gastroschisis: Clinical spectrum and neonatal outcomes at a referral center

AIM OF THE STUDY

To evaluate the outcomes of neonates with complex gastroschisis (GC), and correlate outcomes with each type of complication.

METHODS

Retrospective review of patients with complex GC owing to prenatal and/or postnatal abdominal complications; 2008-2016. Primary outcomes: time to discontinue parenteral nutrition (off-PN), length of stay (LOS) and neonatal survival.

MAIN RESULTS

We treated 58 patients with complex gastroschisis owing to abdominal complications, which were: intestinal necrosis at birth (n=9), intestinal atresia (n=16), medical necrotizing enterocolitis (NEC) (n=15), surgical NEC (n=1), in utero volvulus (n=1), vanishing gastroschisis (n=2), severe intestinal dysmotility (n=1), delayed abdominal closure (n=3), abdominal compartment syndrome (n=2) and hiatal hernia/severe gastroesophageal reflux disease (GERD; n=11). The off-PN time and LOS of the whole group were 92 (35-255) and 119 (42-282) days, significantly longer than those of a demographically equivalent contemporaneous series of 125 patients with uncomplicated gastroschisis (off-PN 32 [12-105] days [p<0.001]; LOS 41 [18-150] days [p<0.001]). Patients with intestinal necrosis at birth or with intestinal atresia had the longest off-PN and LOS times (133 [38-255] / 157 [43-282] and 114 [36-222] / 143 [42-262] days, respectively), followed by patients with complications of the abdominal wall closure (n=5) (69 [43-93] / 89 [58-110] days), patients with hiatal hernias/severe GERD who required fundoplication (63 [35-84] / 89 [57-123] days) and patients who developed medical NEC (67 [35-103] / 76 [50-113] days). Short-bowel syndrome/PN-dependence occurred in 6/58 (10%) patients (2 vanishing gastroschisis, 1 in utero volvulus, 2 intestinal atresias and 1 bowel necrosis at birth). There were no neonatal mortalities.

CONCLUSION

Gastroschisis can be complicated by a wide variety of prenatal and postnatal events. The most severe outcomes occur in patients with bowel necrosis at birth, intestinal atresias, or vanishing gastroschisis. Complications, however, did not affect neonatal survival in our experience.

LEVEL OF EVIDENCE

III.

Advances in prenatal and perinatal diagnosis and management of gastroschisis

Gastroschisis is a congenital, ventral wall defect associated with bowel evisceration. The defect is usually to the right of the umbilical cord insertion and requires postnatal surgical correction. The fetus is at risk for complications such as intrauterine growth restriction, preterm delivery, and intrauterine fetal demise. In addition, complex cases, defined by the presence of intestinal complications such as bowel atresia, stenosis, perforation, or ischemia, occur in up to one third of pregnancies affected by gastroschisis. As complex gastroschisis is associated with increased morbidity and mortality, research has focused on the prenatal detection of this high risk subset of cases. The purpose of this review is to discuss the prenatal, diagnostic approach to the identification of gastroschisis, to describe potential signs of complex gastroschisis on prenatal ultrasound, to review current guidelines for antepartum management and delivery planning, and to summarize results of both past and current intervention trials in fetuses with gastroschisis.

The influence of gestational age, mode of delivery and abdominal wall closure method on the surgical outcome of neonates with uncomplicated gastroschisis

AIM OF THE STUDY

To evaluate if gestational age (GA), mode of delivery and abdominal wall closure method influence outcomes in uncomplicated gastroschisis (GTC).

METHODS

Retrospective review of NICU admissions for gastroschisis, August 2008-July 2016. Primary outcomes were: time to start enteral feeds (on-EF), time to discontinue parenteral nutrition (off-PN), and length of stay (LOS).

MAIN RESULTS

A total of 200 patients with GTC were admitted to our NICU. Patients initially operated elsewhere (n = 13) were excluded. Patients with medical/surgical complications (n = 62) were analyzed separately. The study included 125 cases of uncomplicated GTC. There were no statistically significant differences in the outcomes of patients born late preterm (34 0/7-36 6/7; n = 70) and term (n = 40): on-EF 19 (5-54) versus 17 (7-34) days (p = 0.29), off-PN 32 (12-101) versus 30 (16-52) days (p = 0.46) and LOS 40 (18-137) versus 37 (21-67) days (p = 0.29), respectively. Patients born before 34 weeks GA (n = 15) had significantly longer on-EF, off-PN and LOS times compared to late preterm patients: 26 (12-50) days (p = 0.01), 41 (20-105) days (p = 0.04) and 62 (34-150) days (p < 0.01), respectively. There were no significant differences in outcomes between patients delivered by C-section (n = 62) and patients delivered vaginally (n = 63): on-EF 20 (5-50) versus 19 (7-54) days (p = 0.72), off-PN 32 (12-78) versus 33 (15-105) days (p = 0.83), LOS 42 (18-150) versus 41 (18-139) days (p = 0.68), respectively. There were significant differences in outcomes between patients who underwent primary reduction (n = 37) and patients who had a silo (88): on-EF 15 (5-37) versus 22 (6-54) days (p < 0.01), off-PN 28 (12-52) versus 34 (15-105) days (p = 0.04), LOS 36 (18-72) versus 44 (21-150) days (p = 0.04), respectively.

CONCLUSION

In our experience, late preterm delivery did not affect outcomes compared to term delivery in uncomplicated GTC. Outcomes were also not influenced by the mode of delivery. Patients who underwent primary reduction had better outcomes than patients who underwent silo placement.

High mortality among children with gastroschisis after the neonatal period: A long-term follow-up study

BACKGROUND

During the last decades neonatal outcomes for children born with gastroschisis have improved significantly. Survival rates >90% have been reported. Early prenatal diagnosis and increased survival enforce the need for valid data for long-term outcome in the pre- and postnatal counseling of parents with a child with gastroschisis.

METHODS

Long-term follow-up on all newborns with gastroschisis at Odense University Hospital (OUH) from January 1 1997-December 31 2009. Follow-up included neonatal chart review for neonatal background factors, including whether a GORE^®DUALMESH was used for staged closure, electronic questionnaires, interview and laboratory investigations. Cases were divided into complex and simple cases according to the definition by Molik et al. (2001). Survival status was determined by the national personal identification number registry. Because of the consistency of the registration, survival status was obtained from all children participating in the study.

RESULTS

A total of 71 infants (7 complex and 64 simple) were included. Overall seven out of the 71 children (9.9%, median age: 52days (25-75% percentile 0-978days) had died at the time of follow-up. Three died during the neonatal period and four died after the neonatal period. Parenteral nutrition (PN) induced liver failure and suspected adhesive small bowel obstruction were the causes of deaths after the neonatal period. Overall mortality was high in the "complex" group compared to the simple group (3/7 (42.9%) vs 4/64 (6.3%), p = 0.04). Forty (62.5%) of the surviving children consented to participate in the follow-up. A total of 12 children had had suspected adhesive small bowel obstruction. Prevalence of small bowel obstruction was not related to the number of operations needed for neonatal closure of the defect. Staged closure was done in 5/12 (41.7%) who developed small bowel obstruction vs 11/35 (31.43%) without small bowel obstruction, p=0.518. A GORE^®DUALMESH was used in 16 children (22.5%). Of these 2 were complex and 14 were simple cases. Prevalence of recurrent abdominal pain was 22.5% (9/40) among children with gastroschisis compared to 12% in a study on Danish school children, p=0.068. Gastrointestinal symptoms had led to hospital admission after primary discharge in significantly more children with gastroschisis 16 (40.0%) than children younger than 16years old in the general Danish population 129.419/1.081.542 (12.0%), p=0.000. Fecal calprotectin level was above the reference level (>50mg/kg) in 6/16 (37.5%) children >8years old with gastroschisis compared to 1/7 (14.3%) healthy children. (Fisher's exact=0.366). Only 8/38 (21.1%) children with gastroschisis reported to have an umbilicus.

CONCLUSION

Mortality among children with gastroschisis is still significant with the highest risk among complicated cases. The majority of the deaths is potentially preventable as PN-related causes and suspected adhesive small bowel obstruction counted for five of seven deaths. Neither categorization upon method of abdominal wall closure nor categorization into simple and complex cases can predict the risk of adhesive small bowel obstruction. With improved administration of PN and timely information and attention to the risk of the small bowel obstruction there is good possibility that the associated mortality could decrease. Type of study and level of evidence: Prognosis study, level II.

Gastroschisis: A Review of Management and Outcomes

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, and maternal serum α-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.

Sonographic markers associated with adverse neonatal outcomes among fetuses with gastroschisis: an 11-year, single-center review

BACKGROUND

Gastroschisis complicates 1 in 2000 births and is readily identifiable during prenatal ultrasound scans. Outcomes in fetuses that are affected by gastroschisis vary widely from stillbirth or neonatal death to uncomplicated surgical correction, which makes prenatal counseling challenging.

OBJECTIVE

The goal of our study was to identify sonographic markers that are associated with perinatal death and morbidity that include significant bowel injury, necrotizing enterocolitis, and the need for bowel resection in fetuses with gastroschisis.

STUDY DESIGN

We identified a cohort of fetuses that were diagnosed with gastroschisis from 2003-2014. Sonographic markers that were reviewed included growth restriction, abdominal circumference, oligohydramnios, bowel dilation, and gastric bubble characteristics. We evaluated these markers both at diagnosis and near delivery. Four adverse perinatal outcomes were assessed: perinatal death, necrotizing enterocolitis, need for bowel resection, and a composite of significant bowel injury, which included a diagnosis of bowel atresia or necrosis at the time of surgical exploration. Logistic regression was performed to calculate odds ratios and 95% confidence intervals for each marker and outcome.

RESULTS

One hundred seventy-seven patients were identified, and 154 of these patients met inclusion criteria after exclusions for delivery <24 weeks gestation, other associated anomalies, lethal karyotype, or lost to follow-up evaluation. Markers at the time of diagnosis (median gestational age, 21 weeks [25th,75th interquartile range, 19, 24 weeks]) that were associated with perinatal death were abdominal circumference <5th percentile (odds ratio, 5.56; 95% confidence interval, 1.25-24.76), abnormal gastric bubble (odds ratio, 11.20; 95% confidence interval, 2.15-58.33), and abnormal stomach location (odds ratio, 17.1; 95% confidence interval, 2.99-97.85). An abnormal stomach location (odds ratio, 5.53; 95% confidence interval, 1.03-29.72) before delivery was associated with perinatal death. Gastric dilation before delivery (odds ratio, 4.36; 95% confidence interval, 1.10-17.34)] was associated with the need for bowel resection.

CONCLUSION

Early sonographic markers of increased perinatal mortality rates include abdominal circumference <5th percentile and an abnormal gastric bubble.

Prenatal Risk Factors and Outcomes in Gastroschisis: A Meta-Analysis

BACKGROUND AND OBJECTIVE

Gastroschisis is a congenital anomaly with increasing incidence, easy prenatal diagnosis and extremely variable postnatal outcomes. Our objective was to systematically review the evidence regarding the association between prenatal ultrasound signs (intraabdominal bowel dilatation [IABD], extraabdominal bowel dilatation, gastric dilatation [GD], bowel wall thickness, polyhydramnios, and small for gestational age) and perinatal outcomes in gastroschisis (bowel atresia, intra uterine death, neonatal death, time to full enteral feeding, length of total parenteral nutrition and length of in hospital stay).

METHODS

Medline, Embase, and Cochrane databases were searched electronically. Studies exploring the association between antenatal ultrasound signs and outcomes in gastroschisis were considered suitable for inclusion. Two reviewers independently extracted relevant data regarding study characteristics and pregnancy outcome. All meta-analyses were computed using individual data random-effect logistic regression, with single study as the cluster unit.

RESULTS

Twenty-six studies, including 2023 fetuses, were included. We found significant positive associations between IABD and bowel atresia (odds ratio [OR]: 5.48, 95% confidence interval [CI] 3.1-9.8), polyhydramnios and bowel atresia (OR: 3.76, 95% CI 1.7-8.3), and GD and neonatal death (OR: 5.58, 95% CI 1.3-24.1). No other ultrasound sign was significantly related to any other outcome.

CONCLUSIONS

IABD, polyhydramnios, and GD can be used to an extent to identify a subgroup of neonates with a prenatal diagnosis of gastroschisis at higher risk to develop postnatal complications. Data are still inconclusive on the predictive ability of several signs combined, and large prospective studies are needed to improve the quality of prenatal counseling and the neonatal care for this condition.

Factors associated with gastroschisis outcomes

OBJECTIVE

To identify perinatal variables associated with adverse outcomes in neonates prenatally diagnosed with gastroschisis.

METHODS

A retrospective review was conducted of all inborn pregnancies complicated by gastroschisis within the five institutions of the University of California Fetal Consortium from 2007 to 2012. The primary outcome was a composite adverse neonatal outcome comprising death, reoperation, gastrostomy, and necrotizing enterocolitis. Variables collected included antenatal ultrasound findings, maternal smoking or drug use, gestational age at delivery, preterm labor, elective delivery, mode of delivery, and birth weight. Univariate and multivariate analysis was used to assess factors associated with adverse outcomes. We also evaluated the association of preterm delivery with neonatal outcomes such as total parenteral nutrition cholestasis and length of stay.

RESULTS

There were 191 neonates born with gastroschisis in University of California Fetal Consortium institutions at a mean gestational age of 36 3/7±1.8 weeks. Within the cohort, 27 (14%) had one or more major adverse outcomes, including three deaths (1.6%). Early gestational age at delivery was the only variable identified as a significant predictor of adverse outcomes on both univariate and multivariate analysis (odds ratio 1.4, 95% confidence interval 1.1-1.8 for each earlier week of gestation). Total parenteral nutrition cholestasis was significantly more common in neonates delivered at less than 37 weeks of gestation (38/115 [33%] compared with 11/76 [15%]; P<.001).

CONCLUSION

In this contemporary cohort, earlier gestational age at delivery is associated with adverse neonatal outcomes in neonates with gastroschisis. Other variables, such as antenatal ultrasound findings and mode of delivery, did not predict adverse neonatal outcomes.

Gastroschisis: antenatal sonographic predictors of adverse neonatal outcome

Objectives. The aim of this review was to identify clinically significant ultrasound predictors of adverse neonatal outcome in fetal gastroschisis. Methods. A quasi-systematic review was conducted in PubMed and Ovid using the key terms “gastroschisis,” “predictors,” “outcome,” and “ultrasound.” Results. A total of 18 papers were included. The most common sonographic predictors were intra-abdominal bowel dilatation (IABD), intrauterine growth restriction (IUGR), and bowel dilatation not otherwise specified (NOS). Three ultrasound markers were consistently found to be statistically insignificant with respect to predicting adverse outcome including abdominal circumference, stomach herniation and dilatation, and extra-abdominal bowel dilatation (EABD). Conclusions. Gastroschisis is associated with several comorbidities, yet there is much discrepancy in the literature regarding which specific ultrasound markers best predict adverse neonatal outcomes. Future research should include prospective trials with larger sample sizes and use well-defined and consistent definitions of the adverse outcomes investigated with consideration given to IABD.

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.

Outcomes of early versus late intestinal operations in patients with gastroschisis and intestinal atresia: results from a prospective national database

BACKGROUND

Gastroschisis may be complicated by intestinal atresia, necrosis, and/or perforation. In the absence of an urgent indication, intestinal procedures are often delayed to allow for bowel recovery. This practice has not been evaluated.

METHODS

We queried a prospective Canadian database of all patients with gastroschisis born between 2005 and 2011. Patients with intestinal atresia who underwent an intestinal operation during the first 21 days of life (EARLY GROUP) were compared with those who underwent operations later (LATE GROUP).

RESULTS

Of 629 gastroschisis patients, 78 (12.4%) had intestinal complications; 27 patients (4.3%) had intestinal operations for atresia without necrosis or perforation - 14 EARLY and 13 LATE. Baseline clinical parameters were similar between the two groups. There was a decreased incidence of the following complications in the EARLY group but none reached statistical significance: post-operative bowel obstruction (28.6% vs. 61.5%, p = 0.1); line sepsis (14.3% vs. 30.8 %, p = 0.4); and wound infection (14.3% vs. 46.1%, p = 0.1). Earlier tolerance of enteral feeding in the EARLY group was manifested by younger age at first enteral feeding (14.8 + 2.6 vs. 44.7 + 7.4 days, p = 0.002) and higher tolerance of enteral feeding at 28 days of life [less patients exclusively on TPN (28.6% vs. 61.5%, p = 0.06), and more patients on more than 50 cc kg(-1)day(-1) of enteral feeding (42.9% vs. 7.7%, p = 0.08)].

CONCLUSIONS

Early intestinal operations in patients with gastroschisis and intestinal atresia are not associated with increased complications, and allow patients to receive and tolerate enteral feeding earlier.

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.

Gastric contractility in experimental gastroschisis

BACKGROUND/PURPOSE

The mechanism of fetal gastric dilation in gastroschisis is controversial. This study was designed to characterize changes in the contractile profile of strips of stomach from rats following experimental gastroschisis.

METHODS

Pregnant Wistar rats were operated on day 18.5. Fetuses were divided into three groups: gastroschisis (G), sham (S), and control (C). On day 21.5, gastric fundus and antrum strips were obtained and suspended to a force transducer connected to a digital data acquisition system. They were submitted to increasing concentrations of carbachol (CCh) and weighed at the end of each procedure. Frequency and amplitude of each contraction were evaluated.

RESULTS

Under basal conditions, spontaneous oscillatory contractions of antrum and fundus strips of G, S, and C were similar (P>0.05; ANOVA). However, cumulative concentrations of CCh (0.01-100 μM) produced different effects in all groups and were characterized by a significant increase in amplitude and frequency of spontaneous contractions in antral smooth muscle and a sustained increase in tonus in fundic strips. Upon analysis, no significant difference in frequency or amplitude was noted in antral tissues comparing C to G and to S (P>0.05). No significant contractility difference was noted in fundic smooth muscle (comparing all groups, P>0.05), with the CCh-induced curve following a typical sigmoidal format, dependent on increasing concentrations (P<0.001).

CONCLUSIONS

Gastric contractile responses to CCh are preserved in experimental gastroschisis. These results do not support the theory that gastric dilation occurs secondary to intestinal inflammation alone.

Advances in surgery for abdominal wall defects: gastroschisis and omphalocele

Abdominal wall defects (AWDs) are a common congenital surgical problem in fetuses and neonates. The incidence of these defects has steadily increased over the past few decades due to rising numbers of gastroschisis. Most of these anomalies are diagnosed prenatally and then managed at a center with available pediatric surgical, neonatology, and high-risk obstetric support. Omphaloceles and gastroschisis are distinct anomalies that have different management and outcomes. There have been a number of recent advances in the care of patients with AWDs, both in the fetus and the newborn, which will be discussed in this article.

Bowel-defect disproportion in gastroschisis: does the need to extend the fascial defect predict outcome?

BACKGROUND/PURPOSE

Validated outcome prediction for gastroschisis (GS) permits early risk stratification. The aim of our study was to determine whether the need for GS defect extension: (a) correlates with bowel injury severity at birth, and (b) predicts outcome.

METHODS

A national dataset was used to study GS babies born between 2005 and 2010. The primary outcome was days of parenteral nutrition (PN). Outcomes were analyzed according to the need for fascial extension to facilitate closure or silo placement as follows: Group 1, no extension; Group 2A, extension <2 cm; Group 2B, extension >2 cm. Univariate and where appropriate, multivariate analyses were used.

RESULTS

Of 507 cases, 402 had complete defect extension data: Group 1, 297 (73%); Group 2A, 67 (17%); Group 2B, 42 (10%). Group 2B patients had higher rates of atresia, perforation and severe matting (P = 0.001) and required more days on PN compared to Group 1 (63.0 ± 100.4 vs. 39.7 ± 44.5 days: CI 1.2-45.1; P = 0.03). Multivariate analysis revealed that the presence of atresia (P = 0.01) and surgical site (P = 0.001) or bloodstream (P = 0.001) infections were predictive of prolonged PN; however, the need for fascial extension was not.

CONCLUSIONS

GS newborns who require fascial extension are more likely to have complicated GS and are at greater risk for adverse outcome, although it is not an independent predictor of the latter.

Is complex gastroschisis predictable by prenatal ultrasound?

OBJECTIVE

To establish a correlation between prenatal ultrasound findings and postnatal outcome in neonates with gastroschisis (GS).

DESIGN

Retrospective case-control study.

SETTING

Prenatal ultrasound reports, labour and neonatal intensive care unit notes, and paediatric surgical clinic records were reviewed.

POPULATION

Neonates with an antenatal diagnosis of isolated GS.

METHODS

The neonates were divided into two groups: one with associated bowel complications including intestinal atresia, perforation, necrosis or volvulus ('complex' GS), and the second without bowel complication ('simple' GS). Prenatal ultrasound markers: small-for-gestational-age, intra-abdominal and extra-abdominal bowel dilatation (>6 mm), thickened intestinal wall and stomach dilatation were correlated with outcome.

MAIN OUTCOME MEASURES

Fetal or neonatal death in complex versus simple GS. Time on parenteral nutrition and duration of hospital stay were also noted.

RESULTS

In all, 105 cases were eligible for analysis. Survival rate was 101/105 (96.2%). None of the ultrasound markers was predictive of fetal or neonatal death. Fourteen of 103 live-born babies (14.6%) had complex GS, which was associated with longer time on parenteral nutrition [8.0 (51.5-390) versus 33.5 (25.3-53.3) days, P<0.001] and longer duration of hospital stay [85.3 (55.5-210) versus 41.5 (33.0-64.8) days, P<0.001]. Infants with complex GS were more likely to require bowel resection and stoma placement (P<0.05). Intra-abdominal bowel dilatation was the only predictive ultrasound marker of complex GS (odds ratio 4.13, 95% CI 1.32-12.90; P=0.018). Receiver operating characteristic curve for observed/expected bowel diameter yielded 6 as the cutoff value for predicting complex GS (odds ratio 7.9, 95% CI 2.3-27.3; P=0.001) with 54% and 88% for sensibility and specificity, respectively.

CONCLUSIONS

Intra-abdominal bowel dilatation is the only ultrasound marker predictive of complex GS but it is a strong marker.