1
|
Simon R, Shay R, Bergam B, Katz R, Delaney S. Gastroschisis ultrasound bowel characteristics demonstrate minimal impact on perinatal outcomes. J Neonatal Perinatal Med 2023; 16:639-647. [PMID: 38043025 DOI: 10.3233/npm-230159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
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.
Collapse
Affiliation(s)
- R Simon
- Department of Ob/Gyn, University of Washington, Seattle, WA, USA
| | - R Shay
- Department of Ob/Gyn, University of Washington, Seattle, WA, USA
| | - B Bergam
- School of Medicine, University of Washington, Seattle, WA, USA
| | - R Katz
- Department of Ob/Gyn, University of Washington, Seattle, WA, USA
| | - S Delaney
- Department of Ob/Gyn, University of Washington, Seattle, WA, USA
| |
Collapse
|
2
|
Sun RC, Hessami K, Krispin E, Pammi M, Mostafaei S, Joyeux L, Deprest J, Keswani S, Lee TC, King A, Belfort MA, Shamshirsaz AA. Prenatal ultrasonographic markers for prediction of complex gastroschisis and adverse perinatal outcomes: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022; 107:371-379. [PMID: 34607856 DOI: 10.1136/archdischild-2021-322612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/17/2021] [Indexed: 11/03/2022]
Abstract
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.
Collapse
Affiliation(s)
- Raphael C Sun
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon, USA.,Division of Fetal Therapy and Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Eyal Krispin
- Division of Fetal Therapy and Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Mohan Pammi
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Shayan Mostafaei
- Department of Biostatistics, Faculty of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran (the Islamic Republic of)
| | - Luc Joyeux
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, Leuven, Belgium
| | - Jan Deprest
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, Katholieke Universiteit Leuven, Leuven, Belgium.,Institute of Women's Health, University College London Hospitals, University College London Medical School, London, UK
| | - Sundeep Keswani
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Timothy C Lee
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Alice King
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Michael A Belfort
- Division of Fetal Therapy and Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Division of Fetal Therapy and Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
3
|
Kapapa M, Rieg T, Serra A. Does meconium contaminated amniotic fluid affect intestinal wall thickness and functional outcome in patients with anterior abdominal wall defects? Afr J Paediatr Surg 2022; 19:46-51. [PMID: 34916352 PMCID: PMC8759423 DOI: 10.4103/ajps.ajps_8_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Gastroschisis (GS) and omphalocele (OC) are congenital abdominal wall defects, the main difference between is the direct exposure of intestinal loops in amniotic fluid in children with a GS. This leads to a reduced primary closure rate and a higher number of intraoperative abnormalities and post-operative complications. AIMS AND OBJECTIVES We analysed abdominal wall defect patients over an 11-year period, aiming to assess the influence of meconium-contaminated amniotic fluid. This study has different objectives to show the consequence of functional outcome of abdominal wall defects (AWD) children in reliance to colour of amniotic fluid, to assess the effect of reduced bowel exposure time to meconium contaminated amniotic fluid on edematous inflammatory thickening of the bowel loops, to show an positively influence in the number of primary AWD closures, to demonstrate a reduced incidence of post-natal complications and to verify a better outcome of OC children because of failing exposure to amniotic fluid. METHODS A retrospective, observational case-control design was used to compare GS (n = 36) and OC (n = 18) children. Physical data, colour of amniotic fluid, pre- and perinatal problems, operative complications and surgical technique, post-operative complications, duration of intensive care unit (ICU) stay, mechanical ventilation, parenteral nutrition, commencement of oral feeding and total hospital stay were collected. Data were analysed with descriptive methods, t-test and non-parametric tests such as Wilcoxon and Kruskal-Wallis were performed in addition to the analysis of variance, including post hoc testing accepting a confidence interval of 95% (P < 0.05) by using IBM SPSS software, version 23 (IBM, Illinois, USA). RESULTS Rate of meconium-contaminated amniotic fluid is significantly higher in GS compared to OC (P < 0.001), delivery problems such as congenital infections are also significantly higher (P < 0.001), this yields in significantly more bowel loops anomalies and problems during surgery (P < 0.036) but had no significant influence on primary abdominal wall closures rate (P = 0.523). The post-surgical outcome of OC was significantly better as compared to GS. Within the GS, those with swollen intestines had significantly longer ICU stays (P = 0.045) due to extended mechanical ventilation (P = 0.007), parenteral nutrition (P = 0.011) and delayed initiation of oral feeding (P < 0.001. Same results were found for the duration of ICU stay (P = 0.008), mechanical ventilation (P = 0.006), parenteral nutrition (P = 0.011) and delayed initiation of oral feeding (P < 0.001) in secondary closures as compared to primary abdominal wall closures in the GS group. CONCLUSIONS Worsen functional short-term outcome of GS children was directly addicted to meconium contamination of amniotic fluid due to swollen intestines and because of this more post-surgical problem including significantly extended hospital stays were observed.
Collapse
Affiliation(s)
- Melanie Kapapa
- Department of Surgery, Division of Pediatric Surgery, University Ulm Medical Centre, Eythstrasse, Ulm, Germany
| | - Teresa Rieg
- Department of Gynaecology and Obstetrics, Hospital Heidenheim, Heidenheim an der Brenz, Germany
| | - Alexandre Serra
- Department of Surgery, Division of Pediatric Surgery, University Ulm Medical Centre, Eythstrasse, Ulm, Germany
| |
Collapse
|
4
|
Geslin D, Clermidi P, Gatibelza ME, Boussion F, Saliou AH, Le Manac'h Dove G, Margaryan M, De Vries P, Sentilhes L, Levard G, Lardy H, Arnaud A, Leclair MD, Podevin G, Schmitt F. What prenatal ultrasound features are predictable of complex or vanishing gastroschisis? A retrospective study. Prenat Diagn 2017; 37:168-175. [DOI: 10.1002/pd.4984] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/19/2016] [Accepted: 12/09/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Dorothée Geslin
- Paediatric Surgery Department; University Hospital of Angers; Angers France
- Paediatric Surgery Department; University Hospital of Lyon; Lyon France
| | - Pauline Clermidi
- Paediatric Surgery Department; University Hospital of Nantes; Nantes France
- Paediatric Surgery Department; Robert Debré University Hospital; Paris France
| | - Marie-Eve Gatibelza
- Paediatric Surgery Department; University Hospital of Poitiers; Poitiers France
- Paediatric Surgery Department; University Hospital of Rennes; Rennes France
| | - Françoise Boussion
- Department of Obstetrics and Gynecology; Angers University; Angers France
| | - Anne-Hélène Saliou
- Department of Obstetrics and Gynecology; University Hospital of Brest; Brest France
| | | | - Marc Margaryan
- Paediatric Surgery Department; Le Mans Hospital; Le Mans France
| | - Philine De Vries
- Paediatric Surgery Department; University Hospital of Brest; Brest France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology; University Hospital of Bordeaux; Bordeaux France
| | - Guillaume Levard
- Paediatric Surgery Department; University Hospital of Poitiers; Poitiers France
| | - Hubert Lardy
- Paediatric Surgery Department; University Hospital of Tours; Tours France
| | - Alexis Arnaud
- Paediatric Surgery Department; University Hospital of Rennes; Rennes France
| | - Marc-David Leclair
- Paediatric Surgery Department; University Hospital of Nantes; Nantes France
| | - Guillaume Podevin
- Paediatric Surgery Department; University Hospital of Angers; Angers France
| | - Françoise Schmitt
- Paediatric Surgery Department; University Hospital of Angers; Angers France
| |
Collapse
|
5
|
Kim JY, You JY, Chang KHJ, Choi SJ, Oh SY, Seo JM, Roh CR, Kim JH. Association Between Prenatal Sonographic Findings of Duodenal Obstruction and Adverse Outcomes. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:1931-1938. [PMID: 27466262 DOI: 10.7863/ultra.15.09074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 12/23/2015] [Indexed: 06/06/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the association of prenatal sonographic findings with adverse outcomes and the causes of duodenal obstruction. METHODS A total of 59 cases of congenital duodenal obstruction were included in this study. The sonographic findings, including the degree of duodenal dilatation, polyhydramnios, and their change over gestation, were investigated. Adverse outcomes were defined as fetal death in utero, postnatal death, and gastrointestinal complications requiring readmission or reoperation during the follow-up period. The cause of duodenal obstruction was also assessed. RESULTS Among the patients studied, 2 (3.4%) had fetal death in utero and 2 (3.5%) had postnatal death. Gastrointestinal complications requiring readmission or reoperation occurred in 10.9%. In the cases with or without adverse outcomes, no significant differences were observed in the prenatal sonographic findings: maximum duodenal dilatation, mean amniotic fluid index, and the changes in these parameters with advancing gestation. The cases with adverse outcomes were associated with a younger gestational age at delivery compared to the cases without adverse outcomes. Notably, the degree of duodenal dilatation and amniotic fluid volume were greater in duodenal atresia than in other causes of obstruction, including duodenal stenosis, a duodenal web, and an annular pancreas. In the study population, the overall postoperative survival rate was 98.2%. CONCLUSIONS Prenatal sonographic findings of duodenal obstruction were not associated with adverse outcomes; however, they may be helpful for differentiating the cause of duodenal obstruction.
Collapse
Affiliation(s)
- Ji Ye Kim
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul Korea
| | - Ji Yeon You
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul Korea
| | - Kylie Hae-Jin Chang
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul Korea
| | - Suk-Joo Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul Korea
| | - Soo-Young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul Korea
| | - Jeong-Meen Seo
- Department of Surgery, Division of Pediatric Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul Korea
| | - Cheong-Rae Roh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul Korea
| | - Jong-Hwa Kim
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul Korea
| |
Collapse
|
6
|
Raia-Barjat T, Stadler A, Varlet MN, Fanget C, Noblot E, Prieur F, Chauleur C, Varlet F. Accuracy of antenatal ultrasound signs in predicting the risk for bowel atresia in patients with gastroschisis. Eur J Obstet Gynecol Reprod Biol 2016; 203:116-20. [DOI: 10.1016/j.ejogrb.2016.05.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 05/15/2016] [Accepted: 05/21/2016] [Indexed: 12/12/2022]
|
7
|
Kozlov YA, Novozhilov VA, Koval'kov KA, Rasputin AA, Baradieva PZ, Us GP, Kuznetsova NN. [Congenital defects of abdominal wall]. Khirurgiia (Mosk) 2016:74-81. [PMID: 27447007 DOI: 10.17116/hirurgia2016574-81] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yu A Kozlov
- City Ivano-Matreninskaya Children's Clinical Hospital, Irkutsk; Irkutsk State Medical Academy of Postgraduate Education
| | - V A Novozhilov
- City Ivano-Matreninskaya Children's Clinical Hospital, Irkutsk; Irkutsk State Medical Academy of Postgraduate Education; Irkutsk State Medical University
| | | | - A A Rasputin
- City Ivano-Matreninskaya Children's Clinical Hospital, Irkutsk
| | | | - G P Us
- City Ivano-Matreninskaya Children's Clinical Hospital, Irkutsk
| | - N N Kuznetsova
- City Ivano-Matreninskaya Children's Clinical Hospital, Irkutsk
| |
Collapse
|
8
|
Johnston R, Haeri S. Oligohydramnios and growth restriction do not portend worse prognosis in gastroschisis pregnancies. J Matern Fetal Neonatal Med 2016; 29:4055-8. [DOI: 10.3109/14767058.2016.1154939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | - Sina Haeri
- St. David’s North Austin Medical Center Women’s Center of Texas, Austin Maternal–Fetal Medicine, Austin, TX, USA
| |
Collapse
|
9
|
Martillotti G, Boucoiran I, Damphousse A, Grignon A, Dubé E, Moussa A, Bouchard S, Morin L. Predicting Perinatal Outcome from Prenatal Ultrasound Characteristics in Pregnancies Complicated by Gastroschisis. Fetal Diagn Ther 2015; 39:279-86. [DOI: 10.1159/000440699] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/25/2015] [Indexed: 11/19/2022]
Abstract
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.
Collapse
|
10
|
Bauseler A, Funke K, Möllers M, Hammer K, Steinhard J, Borowski M, Müller V, Klockenbusch W, Schmitz R. Outcome of fetuses with gastroschisis after modification of prenatal management strategies. Arch Gynecol Obstet 2015; 294:239-43. [DOI: 10.1007/s00404-015-3961-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/06/2015] [Indexed: 12/13/2022]
|
11
|
de Buys Roessingh AS, Damphousse A, Ballabeni P, Dubois J, Bouchard S. Predictive factors at birth of the severity of gastroschisis. World J Gastrointest Pathophysiol 2015; 6:228-234. [PMID: 26600981 PMCID: PMC4644887 DOI: 10.4291/wjgp.v6.i4.228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/23/2015] [Accepted: 10/27/2015] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
|
12
|
Can Prenatal Ultrasound Predict Secondary Gastrointestinal Complications in Neonates with Gastroschisis? Am Surg 2015. [DOI: 10.1177/000313481508100606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
13
|
Abstract
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.
Collapse
|
14
|
Lepigeon K, Van Mieghem T, Vasseur Maurer S, Giannoni E, Baud D. Gastroschisis--what should be told to parents? Prenat Diagn 2014; 34:316-26. [PMID: 24375446 DOI: 10.1002/pd.4305] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 12/13/2013] [Accepted: 12/14/2013] [Indexed: 11/09/2022]
Abstract
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.
Collapse
Affiliation(s)
- Karine Lepigeon
- Materno-fetal & Obstetrics Research Unit, Department of Obstetrics and Gynecology, University Hospital, 1011, Lausanne, Switzerland
| | | | | | | | | |
Collapse
|
15
|
Colby CE, Carey WA, Blumenfeld YJ, Hintz SR. Infants with prenatally diagnosed anomalies: special approaches to preparation and resuscitation. Clin Perinatol 2012; 39:871-87. [PMID: 23164184 DOI: 10.1016/j.clp.2012.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
When a fetal anomaly is suspected, a multidisciplinary approach to diagnosis, counseling, pregnancy management, surveillance, delivery planning, and neonatal care is critical to creating a comprehensive management plan. This article provides a basic framework for integrating prenatal diagnostic and maternal-fetal care considerations, delivery planning, special resuscitation needs, and immediate and later neonatal care and evaluation into developing a thoughtful management plan for infants with prenatally diagnosed complex anomalies including congenital heart disease, intrathoracic masses, fetal airway obstruction, neural tube defects, abdominal wall defects, and skeletal dysplasia.
Collapse
Affiliation(s)
- Christopher E Colby
- Department of Pediatrics, Neonatal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | | | | | | |
Collapse
|
16
|
Wilson MS, Carroll MA, Braun SA, Walsh WF, Pietsch JB, Bennett KA. Is preterm delivery indicated in fetuses with gastroschisis and antenatally detected bowel dilation? Fetal Diagn Ther 2012; 32:262-6. [PMID: 22813923 DOI: 10.1159/000338925] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 04/18/2012] [Indexed: 01/21/2023]
Abstract
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.
Collapse
Affiliation(s)
- Megan S Wilson
- Junior League Center for Advanced Maternal Fetal Care, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | | | | | | | | | | |
Collapse
|
17
|
Cowan KN, Puligandla PS, Laberge JM, Skarsgard ED, Bouchard S, Yanchar N, Kim P, Lee S, McMillan D, von Dadelszen P. The gastroschisis prognostic score: reliable outcome prediction in gastroschisis. J Pediatr Surg 2012; 47:1111-7. [PMID: 22703779 DOI: 10.1016/j.jpedsurg.2012.03.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 03/05/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Disease-specific outcome predictors are required for gastroschisis. We derived and validated a gastroschisis prognostic score (GPS) based on bowel appearance after birth. METHODS Visual scoring of bowel matting, necrosis, atresia, and perforation generated a novel gastroschisis bowel injury score recorded in a national database. Reweighting of score components by regression analysis led to assessments of model calibration and goodness of fit. The GPS was validated in subsequent cases. RESULTS Records from 225 infants were used for model derivation. Only intestinal necrosis independently predicted mortality by regression analysis (odds ratio, 11.5; 95% confidence interval, 4.2-31.4). Model recalibration identified that a GPS of 4 or more predicted mortality in 75% of nonsurvivors and 99% of survivors (P = .0001). A GPS of 2 or more demonstrated significantly worse survival outcomes compared with scores of 0 or 1 (length of stay: P = .011, days to first enteral feed: P = .013, days on total parenteral nutrition: P = .006). Model validation with 184 new patients yielded continued high-quality discrimination of outcomes. The GPS demonstrated "near-perfect" interobserver reliability between 2 surgeons (κ ≥ 0.86). CONCLUSIONS The GPS allows the accurate and reliable identification of high-risk groups for mortality and morbidity based on bowel appearance at birth. This information can drive discussions regarding family counseling, resource allocation, and new therapies for these patients.
Collapse
Affiliation(s)
- Kyle N Cowan
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Kassa AM, Lilja HE. Predictors of postnatal outcome in neonates with gastroschisis. J Pediatr Surg 2011; 46:2108-14. [PMID: 22075340 DOI: 10.1016/j.jpedsurg.2011.07.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Revised: 07/03/2011] [Accepted: 07/04/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND/PURPOSE The optimal management of neonates with gastroschisis is unclear, and there is a significant morbidity. We performed a review of neonates with gastroschisis treated at our center of pediatric surgery over the last 21 years to determine predictive factors of outcome. METHODS Single-center retrospective analysis of 79 neonates with gastroschisis (1989-2009) was done. Length of hospital stay (LOS), days of parenteral nutrition (PN), and survival were outcome measures. Univariate and multiple regression analyses were used. RESULTS Overall survival was 92%, and primary closure was achieved in 80%. Median LOS was 25 days, and median duration on PN, 17 days. Intestinal atresia, closed gastroschisis, secondary closure, and sepsis were the primary variables associated with poor outcome independent of other variables, but prematurity also affected outcome. Route of delivery and associated malformations were not related to poorer outcome. Necrotizing enterocolitis did not occur in any of our patients. CONCLUSION Outcome in our patients was favorable as measured by survival, LOS, and days on PN. Primary predictors of poor outcome were factors related to short bowel syndrome and secondary closure, indicating a need to further improve treatment of short bowel syndrome.
Collapse
Affiliation(s)
- Ann-Marie Kassa
- Department of Women's and Children's Health, Uppsala University, 751 05 Uppsala, Sweden
| | | |
Collapse
|
19
|
Kuleva M, Khen-Dunlop N, Dumez Y, Ville Y, Salomon LJ. Is complex gastroschisis predictable by prenatal ultrasound? BJOG 2011; 119:102-9. [PMID: 22017923 DOI: 10.1111/j.1471-0528.2011.03183.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- M Kuleva
- Department of Obstetrics, Hôpital Necker Enfants Malades, Assistance Publique, Hôpitaux de Paris, Université Paris Descartes Société Française pour l'Amélioration des Pratiques Echographiques, Paris, France
| | | | | | | | | |
Collapse
|
20
|
Abstract
OBJECTIVE Infants with gastroschisis have significant perinatal morbidity including long hospitalizations and feeding intolerance. Two thirds are premature and 20% are growth restricted. Despite these known risk factors for post-natal complications, little is known about readmission for infants with gastroschisis. Our objective was to determine the frequency and indication for hospital readmission after initial discharge among infants with gastroschisis. STUDY DESIGN Retrospective cohort study. All surviving infants treated for gastroschisis at Cincinnati Children's Hospital Medical Center, born between January 2006 and December 2008 were included. Main outcome measures included the frequency and indication for readmission. Associated neonatal risk factors also were assessed. RESULT Fifty-eight patients were analyzed. Twenty-three (40%) subjects were readmitted (five with multiple readmissions); 65% of readmissions occurred in the first year and 70% involved complications directly related to gastroschisis. The most common reasons for readmission were bowel obstruction and abdominal distention/pain. Median time to readmission directly related to gastroschisis was 23 weeks (range 5 to 92). All three infants with home parenteral nutrition were readmitted. Readmission was not associated with gestational age, birth weight or length of initial hospitalization. CONCLUSION Readmission after initial hospitalization is common in gastroschisis patients. Parental counseling should include education regarding the possibility of complications requiring readmission. Determinants of readmission require further study.
Collapse
|
21
|
Long AM, Court J, Morabito A, Gillham JC. Antenatal diagnosis of bowel dilatation in gastroschisis is predictive of poor postnatal outcome. J Pediatr Surg 2011; 46:1070-5. [PMID: 21683200 DOI: 10.1016/j.jpedsurg.2011.03.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 03/26/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Although gastroschisis infants usually have a good outcome, there remains a cohort of babies who fare poorly. We inquired whether the presence of bowel dilatation in utero is predictive of postnatal course in infants with gastroschisis. METHODS We compared the clinical course of infants who had bowel dilatation with those who did not. Bowel dilatation was defined as more than 20 mm in cross-sectional diameter on ultrasound at any gestational age. Outcome measures used were length of time of parenteral nutrition, death, and surgery for intestinal failure. RESULTS A review of 170 infants with gastroschisis identified 74 who had dilatation of more than 20 mm (43.5%). There was no significant difference in the incidence of intestinal atresia in those with bowel dilatation and those without (P = .07). Those with bowel dilatation spent a longer period on parenteral nutrition. There were significantly more deaths in the group with bowel dilatation (P = .01). There was no significant difference in the number of infants requiring surgery for intestinal failure between the 2 groups (P = .47). CONCLUSIONS We found that sonographically detected bowel dilatation more than 20 mm in utero in fetuses with gastroschisis may have value in predicting clinically significant adverse postnatal outcomes.
Collapse
Affiliation(s)
- Anna-May Long
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | | | | | | |
Collapse
|
22
|
Christison-Lagay ER, Kelleher CM, Langer JC. Neonatal abdominal wall defects. Semin Fetal Neonatal Med 2011; 16:164-72. [PMID: 21474399 DOI: 10.1016/j.siny.2011.02.003] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
Collapse
|
23
|
Snyder CW, Biggio JR, Brinson P, Barnes LA, Bartle DT, Georgeson KE, Muensterer OJ. Effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes. J Pediatr Surg 2011; 46:86-9. [PMID: 21238646 DOI: 10.1016/j.jpedsurg.2010.09.067] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 09/30/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND/PURPOSE This study examined the effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes, with adjustment for key confounding variables. METHODS 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. RESULTS 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). CONCLUSIONS Gestational age and intestinal complications are the major determinants of outcome in gastroschisis. Multidisciplinary prenatal care may facilitate term delivery.
Collapse
Affiliation(s)
- Christopher W Snyder
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | | | | | | | | | | | | |
Collapse
|
24
|
Abstract
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.
Collapse
|
25
|
Garcia L, Brizot M, Liao A, Silva MM, Tannuri AC, Zugaib M. Bowel dilation as a predictor of adverse outcome in isolated fetal gastroschisis. Prenat Diagn 2010; 30:964-9. [DOI: 10.1002/pd.2596] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
26
|
Mears AL, Sadiq JM, Impey L, Lakhoo K. Antenatal bowel dilatation in gastroschisis: a bad sign? Pediatr Surg Int 2010; 26:581-8. [PMID: 20419378 DOI: 10.1007/s00383-010-2600-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2010] [Indexed: 01/05/2023]
Abstract
AIM Foetal bowel dilatation in gastroschisis is traditionally taken to be an indicator of poor prognosis and parents are counselled accordingly. Increased bowel distension is often a factor in the decision for early delivery. The aim of this study was to establish whether a correlation exists between antenatally detected bowel dilatation and the postnatal outcome for babies with gastroschisis. METHODS Antenatal ultrasound scans and subsequent postnatal notes were reviewed for cases of isolated gastroschisis from 2004 to 2008. Bowel dilatation was defined as >10 mm diameter. The type (intra- and/or extra-abdominal dilatation), maximum bowel diameter and gestation at which bowel dilatation was first seen was recorded. Outcome measures included number of days of TPN, type of closure (primary or delayed) and postnatal complications. RESULTS There were 60 antenatal cases of gastroschisis over 5 years. Postnatal notes of 47 were obtained. 38 (81%) had antenatal bowel dilatation, 9 did not. Of those with bowel dilatation, 24 underwent primary closure, 9 required silos, 2 a patch and 3 stomas. Seven (15%) had bowel atresia or necrosis. Three died: NEC, septicaemia and CMV hepatitis. The average time on TPN for those without major complications was 22 days. Of those with no bowel dilatation, 4 had primary closure, 3 a silo, 1 a patch and 1 a stoma. Two had complications requiring further surgery, including one atresia resulting in short gut syndrome. There were no deaths. The mean number of days on TPN was 23. The results also demonstrated no significant correlation between gestation when dilatation was first seen, or degree of dilatation, or both these factors combined, and time of TPN requirement. CONCLUSION These results do not support the current practice of using antenatal bowel dilatation as a prognostic indicator.
Collapse
Affiliation(s)
- Alice L Mears
- Department of Paediatric Surgery, Level 2 Children's Hospital, Oxford and University of Oxford, Headley Way, Oxford OX3 9DU, UK
| | | | | | | |
Collapse
|
27
|
Contro E, Fratelli N, Okoye B, Papageorghiou A, Thilaganathan B, Bhide A. Prenatal ultrasound in the prediction of bowel obstruction in infants with gastroschisis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 35:702-707. [PMID: 20069663 DOI: 10.1002/uog.7514] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To assess the value of prenatal ultrasound in predicting bowel obstruction requiring surgery in fetuses with prenatal diagnosis of gastroschisis. METHODS The database of our center was searched for cases with an antenatal diagnosis of gastroschisis. The ultrasound images were reviewed blindly to assess the presence of intra- or extra-abdominal bowel dilatation. Details of surgical procedures were noted and the discharge letters were obtained. Pediatric follow-up was also obtained from pediatric surgeons, general practitioners or parents. RESULTS In the 10-year period between November 1998 and September 2008 there were 62 cases with a prenatal diagnosis of gastroschisis. Postnatal outcome was not available for five cases, four pregnancies underwent termination and intrauterine fetal demise occurred in five cases. A final population of 48 liveborn infants was available for analysis. Intra-abdominal bowel dilatation was identified in 14 of these 48 fetuses (29.2%) and extra-abdominal bowel dilatation in 30 (62.5%) fetuses on prenatal ultrasound images. Eight fetuses (16.7%) had bowel obstruction. The relative risk of bowel obstruction with intra-abdominal bowel dilatation was 4.05 (95% CI, 1.12-14.70). On the other hand, the relative risk of bowel obstruction with extra-abdominal bowel dilatation was 1.0 (95% CI, 0.37-3.70). Four babies died, two of whom had intra- and one had extra-abdominal bowel dilatation. CONCLUSIONS Intra-abdominal dilatation of the bowel on prenatal ultrasound examination appears to predict postnatal bowel obstruction and the need for surgical resection. Extra-abdominal bowel dilatation is observed frequently on prenatal ultrasound scans, but is not predictive of bowel obstruction.
Collapse
Affiliation(s)
- E Contro
- Academic Department of Obstetrics and Gynaecology, St George's Hospital Medical School, London, UK
| | | | | | | | | | | |
Collapse
|
28
|
Predicting adverse neonatal outcomes in fetuses with abdominal wall defects using prenatal risk factors. Am J Obstet Gynecol 2009; 201:383.e1-6. [PMID: 19716531 DOI: 10.1016/j.ajog.2009.06.032] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2009] [Revised: 05/08/2009] [Accepted: 06/11/2009] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether prenatal variables can predict adverse neonatal outcomes in fetuses with abdominal wall defects. STUDY DESIGN A retrospective cohort study that used ultrasound and neonatal records for all cases of gastroschisis and omphalocele seen over a 16-year period. Cases with adverse neonatal outcomes were compared with noncases for multiple candidate predictive factors. Univariable and multivariable statistical methods were used to develop the prediction models, and effectiveness was evaluated using the area under the receiver operating characteristic curve. RESULTS Of 80 fetuses with gastroschisis, 29 (36%) had the composite adverse outcome, compared with 15 of 33 (47%) live neonates with omphalocele. Intrauterine growth restriction was the only significant variable in gastroschisis, whereas exteriorized liver was the only predictor in omphalocele. The areas under the curve for the prediction models with gastroschisis and omphalocele are 0.67 and 0.74, respectively. CONCLUSION Intrauterine growth restriction and exteriorization of the liver are significant predictors of adverse neonatal outcome with gastroschisis and omphalocele.
Collapse
|
29
|
Chung JH, Norton C, Emil S. Sour grapes: ultrasound abnormalities spurred delivery and neonatal surgery. Am J Obstet Gynecol 2009; 201:332.e1-2. [PMID: 19398096 DOI: 10.1016/j.ajog.2009.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Revised: 01/19/2009] [Accepted: 02/20/2009] [Indexed: 10/20/2022]
|
30
|
Risk stratification in gastroschisis: can prenatal evaluation or early postnatal factors predict outcome? Pediatr Surg Int 2009; 25:319-25. [PMID: 19277683 DOI: 10.1007/s00383-009-2342-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2009] [Indexed: 10/21/2022]
Abstract
PURPOSE The prenatal or postnatal factors that predict complex gastroschisis in patients (atresia, volvulus, necrotic bowel and bowel perforation) remain controversial. We evaluated the prognostic value of prenatal ultrasonographic parameters and early postnatal factors in predicting clinical outcomes. METHODS We analyzed maternal and neonatal records of 46 gastroschisis patients treated from 1998 to 2007. Information regarding demographics, prenatal ultrasound data when available, intrapartum and postnatal course was abstracted from medical records. Outcome variables included survival, ventilator days, TPN days, time to full enteral feeds, complications and length of stay. Univariate or multivariate analysis was used, with P < 0.05 considered as significant. RESULT A total of 75% of complex patients were categorized within 1 week of life. Interestingly, prenatal bowel dilation (>17 mm) and thickness (>3 mm) did not correlate with outcome or risk stratification into simple versus complex (P < 0.05). Complex patients had increased morbidity compared to simple patients (sepsis 58 versus 18%; P = 0.021, NEC 42 versus 9%; P = 0.020, short bowel syndrome 58 versus 3%; P = 0.0001, ventilator days 24 versus 10; P = 0.021; TPN days 178 versus 38; P = 0.0001 and days to full feeds 171 versus 31; P = 0.0001; and length of stay 90 versus 39 days, P = 0.0001). CONCLUSIONS Prenatal bowel wall dilation and/or thickness did not predict complex patients or adverse outcome. Complex gastroschisis patients can be identified postnatally and have substantial morbidity.
Collapse
|
31
|
Houben C, Davenport M, Ade-Ajayi N, Flack N, Patel S. Closing gastroschisis: diagnosis, management, and outcomes. J Pediatr Surg 2009; 44:343-7. [PMID: 19231531 DOI: 10.1016/j.jpedsurg.2008.10.084] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/23/2008] [Indexed: 12/16/2022]
Abstract
PURPOSE Gastroschisis (GS) is defined as a full-thickness abdominal wall defect (usually right-sided) with intestinal prolapse and occasionally other viscera. The defect itself may close around the viscera causing exit or entry level intestinal atresia and ischaemia or midgut infarction, previously described as closed GS. We now report the largest series of infants born with various stages of closing GS describing features, management, and outcome. METHODS The study used a single-centre retrospective review of infants with GS and evidence of defect closure at birth. RESULTS Nine infants (6 girls) with a median of 35 (range, 32-36) weeks of gestation fulfilled criteria for closing GS from a series of 146 (6%) infants born from August 1994 to December 2007. Delivery had been expedited in 6 based on increasing intraabdominal bowel dilatation and suspicion of closing GS on serial antenatal ultrasound. At delivery, 5 had compromised but viable bowel and required intestinal surgery. Three fetuses, all with midgut necrosis, had antenatal scans typical of GS with no additional features. After a variety of surgical procedures, 7 patients are now fully enterally fed, one is parenteral nutrition-dependent. One died of end-stage liver failure secondary to short bowel syndrome. The length of follow-up was 6 (range, 0.5-11) years. CONCLUSIONS Of infants with GS, 6% present with closing abdominal ring. Close antenatal monitoring may prevent severe bowel loss in some cases. After multiple surgical interventions, most have a favorable outcome.
Collapse
Affiliation(s)
- Chris Houben
- Department of Paediatric Surgery, King's College Hospital, London, United Kingdom.
| | | | | | | | | |
Collapse
|
32
|
David AL, Tan A, Curry J. Gastroschisis: sonographic diagnosis, associations, management and outcome. Prenat Diagn 2008; 28:633-44. [DOI: 10.1002/pd.1999] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|
33
|
Abstract
PURPOSE OF REVIEW Abdominal wall defects comprising both gastroschisis and omphalocele remain a source of significant morbidity and mortality, despite the advances in neonatal and pediatric surgical care. Survival has improved over the past few decades, especially with parenteral nutrition and surgical repair. Yet, still, many questions remain regarding the outcome of these anomalies. RECENT FINDINGS Outcomes of abdominal wall defects have been discussed more often in the recent publications, with analysis of databases and evaluation of prenatal series. There have been a number of new prenatal interventions in gastroschisis, and a better understanding of gestational outcomes from omphalocele. Papers have discussed the optimal surgical management of these defects as well. SUMMARY This review helps to bring together the most recent findings regarding outcomes and interventions for abdominal wall defects. It also illustrates the pressing need for a large prospective database to better understand these anomalies and provide better care.
Collapse
|
34
|
Heinig J, Müller V, Schmitz R, Lohse K, Klockenbusch W, Steinhard J. Sonographic assessment of the extra-abdominal fetal small bowel in gastroschisis: a retrospective longitudinal study in relation to prenatal complications. Prenat Diagn 2008; 28:109-14. [PMID: 18186152 DOI: 10.1002/pd.1907] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE An explorative retrospective study following a case-series of fetuses with isolated gastroschisis, to evaluate if small-bowel dilatation may be indicative for emerging obstetric complications. The secondary aim was to establish preliminary normative curves for the external diameter and wall thickness of eventerated fetal small bowel in gastroschisis during the second and third trimester of pregnancy. METHODS AND MATERIALS Fourteen fetuses with isolated gastroschisis were followed at a single center. Repeated ultrasound examinations for fetal surveillance with measurement of fetal small-bowel diameter and wall thickness over the course of pregnancy until delivery were performed. RESULTS Longitudinal data analysis showed significantly increasing bowel diameter and wall thickness of eventerated small bowel with advancing gestation. Dilatation of small bowel more than 25 mm in the third trimester of pregnancy was associated with an increased risk of short-term prenatal complications as fetal distress or intrauterine fetal death (PPV 100%; 95% CI: 29.2-100%, NPV 100%; 95% CI: 71.5-100%). CONCLUSIONS Dilatation of the extra-abdominal fetal small bowel in the third trimester may allow identifying fetuses with increased risk of fetal distress requiring closer monitoring of fetal well-being or delivery in a short interval to prevent impending fetal death.
Collapse
Affiliation(s)
- J Heinig
- Department of Obstetrics and Gynecology, University of Münster, Münster, Germany.
| | | | | | | | | | | |
Collapse
|
35
|
Badillo AT, Hedrick HL, Wilson RD, Danzer E, Bebbington MW, Johnson MP, Liechty KW, Flake AW, Adzick NS. Prenatal ultrasonographic gastrointestinal abnormalities in fetuses with gastroschisis do not correlate with postnatal outcomes. J Pediatr Surg 2008; 43:647-53. [PMID: 18405710 DOI: 10.1016/j.jpedsurg.2007.09.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Revised: 09/10/2007] [Accepted: 09/11/2007] [Indexed: 11/16/2022]
Abstract
PURPOSE In the setting of gastroschisis, the clinical significance of prenatal ultrasound findings of secondary changes in bowel appearance remains unknown. The purpose of this study was to correlate prenatal identification of additional gastrointestinal sonographic abnormalities with postnatal clinical outcome. METHODS A retrospective review was conducted on 64 fetuses with a prenatal diagnosis of gastroschisis treated at the Children's Hospital of Philadelphia from 2000 to 2007. Postnatal outcomes were compared between newborns with additional sonographic gastrointestinal abnormalities and those without secondary changes to the bowel appearance. RESULTS Thirty (47%) patients had at least one gastrointestinal abnormality (eg, bowel dilatation, echogenic bowel, thickened bowel, matted bowel, herniation of the stomach through the abdominal wall defect, or segmental loss of bowel peristalsis) on prenatal ultrasound. There were no significant differences between groups with respect to the time to initial and full enteral nutrition, total hospital stay, requirement for ventilator support, central line infection rates, reoperation rates, or mortality. CONCLUSIONS In the setting of gastroschisis, isolated findings of gastrointestinal abnormalities on prenatal ultrasound do not correlate with adverse postnatal outcome.
Collapse
Affiliation(s)
- Andrea T Badillo
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Skarsgard ED, Claydon J, Bouchard S, Kim PCW, Lee SK, Laberge JM, McMillan D, von Dadelszen P, Yanchar N. Canadian Pediatric Surgical Network: a population-based pediatric surgery network and database for analyzing surgical birth defects. The first 100 cases of gastroschisis. J Pediatr Surg 2008; 43:30-4; discussion 34. [PMID: 18206451 DOI: 10.1016/j.jpedsurg.2007.09.011] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2007] [Accepted: 09/02/2007] [Indexed: 11/17/2022]
Abstract
PURPOSE Outcomes studies for gastroschisis are constrained by small numbers, prolonged accrual, and nonstandardized data collection. The aim of this study is to create a national pediatric surgical network and database for gastroschisis (GS) that tracks cases from diagnosis to hospital discharge. METHODS The 16-center network serves a population of 32 million. Gastroschisis cases are ascertained at prenatal diagnosis. Perinatal data include maternal risk and fetal ultrasound variables, delivery plan and outcome, a postnatal bowel injury score, intended and actual surgical treatment, and neonatal outcomes. Institutional review board-approved data collection conforms to regional privacy legislation. Deidentified data are centralized and accessible for research through the network steering committee. RESULTS To date, 114 cases of pre- and/or postnatal gastroschisis have been uploaded. Of 106 live-born infants (40 [38%] by cesarean delivery), 100 had complete records, and overall survival to discharge was 96%, with a mean survivor length of stay (LOS) of 46 days. Infants treated with attempted urgent closure (61%) had significantly shorter LOS (42 vs 57 days; P = .048) but comparable LOS compared with those treated with silos and delayed closure. Fetal bowel dilation 18 mm or greater did not predict a difference in outcome. CONCLUSION Population-based databases allow rapid case accrual and enable studies that should aid in the identification of optimal perinatal treatment.
Collapse
Affiliation(s)
- Erik D Skarsgard
- Department of Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Murphy FL, Mazlan TA, Tarheen F, Corbally MT, Puri P. Gastroschisis and exomphalos in Ireland 1998-2004. Does antenatal diagnosis impact on outcome? Pediatr Surg Int 2007; 23:1059-63. [PMID: 17701414 DOI: 10.1007/s00383-007-2001-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2007] [Indexed: 11/25/2022]
Abstract
Antenatal detection of anterior abdominal wall defects (gastroschisis and exomphalos) enables detailed prenatal planning and counselling with appropriate intrauterine transfer, delivery in a tertiary referral centre with prompt access to paediatric surgery and early surgical intervention. The authors believed that there was a relatively low rate of antenatal detection in Ireland and that an improved antenatal screening program would allow increased detection thus avoiding emergency retrievals from peripheral obstetric centres. Our hypothesis was that there was a significant difference in management and outcome in children with anterior abdominal wall defects detected antenatally and those detected at birth. All anterior abdominal wall defects in The Republic of Ireland are assessed and closed in two surgical centres, Our Lady's Hospital for Sick Children, and the Children's University Hospital, Dublin. A retrospective review of all admissions in both centres revealed 96 neonates with anterior wall defects (excluding bladder exstrophy and cloaca) over a 7 year period from 1998 to 2004 inclusive. Medical records, operative reports, neonatal databases and admission details were reviewed. The antenatal data search included anomaly detection, prenatal management plan and intrauterine transfer. Perinatal data included place of birth, weight, gestational age, mode of delivery, time to surgery and type of surgery, the time to establish full enteral feeding and the length of hospital stay were used as overall markers of outcome. Fifty-three patients had gastroschisis and 43 exomphalos with an antenatal detection rate of 53% (n = 28) and 34% (n = 15), respectively, with an overall detection rate of 44%. There was no significant difference in the median birth weight (2.83 vs. 2.85 kg), gestational age at birth (37 vs. 37 weeks), time to full feeding (12 vs.14 days) and length of stay (20 vs. 17 days) between those detected antenatally or postnatally, respectively. About 77 had a primary closure performed of which 63 infants had surgery within the first 24 h of life. There was no difference in the time to surgery, frequency of complications or the surgical outcome in either group. Intrauterine transfer did not affect any outcome measure assessed. The demographics and the presence of associated anomalies did not differ between the groups. The hypothesis that antenatal diagnosis in anterior abdominal wall defects improves outcome has been demonstrated to be false. Despite this result, the importance of antenatal screening and prenatal management of complex foetal conditions with consultation with experienced paediatric and neonatal staff is without doubt.
Collapse
Affiliation(s)
- F L Murphy
- Department of Paediatric Surgery, Our Lady's Hospital for Sick Children, Crumlin 12, Dublin 12, Ireland.
| | | | | | | | | |
Collapse
|
38
|
Santiago-Munoz PC, McIntire DD, Barber RG, Megison SM, Twickler DM, Dashe JS. Outcomes of Pregnancies With Fetal Gastroschisis. Obstet Gynecol 2007; 110:663-8. [PMID: 17766615 DOI: 10.1097/01.aog.0000277264.63736.7e] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe pregnancy outcomes with fetal gastroschisis, including the associations of prenatal ultrasound findings with neonatal surgical complications and other morbidities. METHODS 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. RESULTS 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. CONCLUSION 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. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Patricia C Santiago-Munoz
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-9032, USA.
| | | | | | | | | | | |
Collapse
|