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Chen Y, Zhao J, Alganabi M, Mesas-Burgos C, Eaton S, Wester T, Pierro A. Elective Delivery versus Expectant Management for Gastroschisis: A Systematic Review and Meta-Analysis. Eur J Pediatr Surg 2023; 33:2-10. [PMID: 35817335 DOI: 10.1055/a-1896-5345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The optimal timing of delivery for pregnancies complicated by prenatally diagnosed gastroschisis remains controversial. Therefore, the aim of this study was to find whether elective or expectant delivery is associated with improved neonatal outcome. MATERIALS AND METHODS MEDLINE and Embase databases were searched for studies up to 2021 that reported timing of delivery for prenatally diagnosed gastroschisis. A systematic review and meta-analysis were then performed in group 1: moderately preterm (gestational age [GA]: 34-35 weeks) elective delivery versus expectant management after GA 34-35 weeks; and group 2: near-term (GA: 36-37 weeks) elective delivery versus expectant management after GA 36-37 weeks. The following clinical outcomes were evaluated: length of stay (LOS), total parenteral nutrition (TPN) days, bowel morbidity (atresia, perforation, and volvulus), sepsis, time of first feeding, short gut syndrome and respirator days, and mortality. RESULTS Two randomized controlled trials (RCT)s and eight retrospective cohort studies were included, comprising 629 participants. Moderately preterm elective delivery failed to improve clinical outcomes. However, near-term elective delivery significantly reduced bowel morbidity (7.4 vs. 15.4%, relative risk = 0.37; 95% confidence interval [CI]: 0.18, 0.74; p = 0.005; I2 = 0%) and TPN days (mean difference =-13.44 days; 95% CI: -26.68, -0.20; p = 0.05; I2 = 45%) compared to expectant delivery. The mean LOS was 39.2 days after near-term delivery and 48.7 days in the expectant group (p = 0.06). CONCLUSION Based on the data analyzed, near-term elective delivery (GA 36-37 weeks) appears to be the optimal timing for delivery of pregnancies complicated by gastroschisis as it is associated with less bowel morbidity and shorter TPN days. However, more RCTs are necessary to better validate these findings.
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Affiliation(s)
- Yong Chen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jiashen Zhao
- School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mashriq Alganabi
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carmen Mesas-Burgos
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Simon Eaton
- Department of Pediatric Surgery, University College, London Institute of Child Health, London, England
| | - Tomas Wester
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Agostino Pierro
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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Goldstein MJ, Bailer JM, Gonzalez-Brown VM. Preterm vs term delivery in antenatally diagnosed gastroschisis: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2022; 4:100651. [PMID: 35462060 DOI: 10.1016/j.ajogmf.2022.100651] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To review the evidence regarding gestational age at birth, length of stay, sepsis incidence, days on mechanical ventilation, and mortality between preterm and term deliveries in pregnancies complicated by gastroschisis. DATA SOURCES We conducted database searches of PubMed, Cochrane Central Register of Controlled Trials, Embase, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov without language restrictions through August 16, 2021. References of all relevant articles were reviewed. STUDY ELIGIBILITY CRITERIA Randomized controlled trials, nonrandomized controlled trials, and observational studies were evaluated comparing length of stay, sepsis, days on mechanical ventilation, and mortality between either elective preterm delivery and expectant management (Group 1) or preterm gestational age and term gestational age (Group 2). METHODS Two researchers independently selected studies and evaluated risk of bias with the Risk of Bias 2 tool for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies. Mean differences and odds ratios were calculated using a random-effects model for inclusion and methodological quality. The primary outcome was length of stay. Secondary outcomes were incidence of sepsis, mortality, days on mechanical ventilation, and gestational age. RESULTS Thirty studies with a total of 7409 patients were included in the systematic review, of which 25 were included in the analysis. Group 1 studies found no difference in length of stay or mortality and a trend toward fewer days on mechanical ventilation (mean difference, -0.40; 95% confidence interval, -0.89 to -0.10; P=.12; I2=35%). Subgroup analysis excluding premature delivery demonstrated lower sepsis incidence in elective preterm delivery (odds ratio, 0.46; 95% confidence interval, 0.25-0.84; P=.01; I2=0%). Group 2 studies found increased length of stay (mean difference, 15.44; 95% confidence interval, 8.44-21.83; P<.00001; I2=94%), sepsis (odds ratio, 1.69; 95% confidence interval, 1.15-2.50; P=.008; I2=51%), days on mechanical ventilation (mean difference, 1.38; 95% confidence interval, 0.10-2.66; P=.03; I2=66%), and mortality (odds ratio, 2.97; 95% confidence interval, 1.59-5.55; P=.0007; I2=0%). Gestational age was significantly lower in Group 2 studies than in Group 1 studies. CONCLUSION Data continue to be conflicting, but subgroup analysis suggested a possible reduction in sepsis incidence and mean days on mechanical ventilation with elective early term delivery.
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Affiliation(s)
| | - Jessica Marie Bailer
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Veronica Mayela Gonzalez-Brown
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX
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Outcome and management in neonates with gastroschisis in the third millennium-a single-centre observational study. Eur J Pediatr 2022; 181:2291-2298. [PMID: 35226141 PMCID: PMC9110488 DOI: 10.1007/s00431-022-04416-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 02/02/2023]
Abstract
UNLABELLED Gastroschisis is one of the most common congenital malformations in paediatric surgery. However, there is no consensus regarding the optimal management. The aims of this study were to investigate the management and outcome and to identify predictors of outcome in gastroschisis. A retrospective observational study of neonates with gastroschisis born between 1999 and 2020 was undertaken. Data was extracted from the medical records and Cox regression analysis was used to identify predictors of outcome measured by length of hospital stay (LOS) and duration of parenteral nutrition (PN). In total, 114 patients were included. Caesarean section was performed in 105 (92.1%) at a median gestational age (GA) of 36 weeks (range 29-38) whereof (46) 43.8% were urgent. Primary closure was achieved in 82% of the neonates. Overall survival was 98.2%. One of the deaths was caused by abdominal compartment syndrome and one patient with intestinal failure-associated liver disease died from sepsis. None of the deceased patients was born after 2005. Median time on mechanical ventilation was 22 h. Low GA, staged closure, intestinal atresia, and sepsis were independent predictors of longer LOS and duration on PN. In addition, male sex was an independent predictor of longer LOS. CONCLUSION Management of gastroschisis according to our protocol was successful with a high survival rate, no deaths in neonates born after 2005, and favourable results in LOS, duration on PN, and time on mechanical ventilation compared to other reports. Multicentre registry with long-term follow-up is required to establish the best management of gastroschisis. WHAT IS KNOWN • Gastroschisis is one of the most common congenital malformations in paediatric surgery with increasing incidence. • There is no consensus among clinicians regarding the optimal management of gastroschisis. WHAT IS NEW • Although primary closure was achieved in 82% of the patients, mortality rate was very low (1.8%) with no deaths in neonates born after 2005 following the introduction of measurement of intraabdominal pressure at closure. • Low gestational age, staged closure, intestinal atresia, sepsis, and male sex were independent predictors of longer length of hospital stay.
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The association between fluid restriction and hyponatremia in newborns with gastroschisis. Am J Surg 2021; 221:1262-1266. [PMID: 33714519 DOI: 10.1016/j.amjsurg.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/01/2021] [Accepted: 03/01/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Newborns with gastroschisis require appropriate fluid resuscitation but are also at risk for hyponatremia that may lead to adverse outcomes. The etiology of hyponatremia in gastroschisis has not been defined. METHODS Over a 24-month period, all newborns with gastroschisis in a free-standing pediatric hospital had sodium levels measured from serum, urine, gastric output, and the bowel bag around the eviscerated contents for the first 48 h of life. Total fluid intake and output were measured. Maintenance fluids were standardized at 120 mL/kg/day. Hyponatremia was defined as a serum sodium <132 mEq/L. A logistic regression model was created to determine independent predictors of hyponatremia. RESULTS 28 infants were studied, and 14 patients underwent primary closure. While serum sodium was normal in all patients at birth, 9 (32%) infants developed hyponatremia at a median of 17.4 h of life. On univariate analysis, hyponatremic babies had a greater net positive fluid balance (74.9 vs 114.7 mL/kg, p = 0.001) primarily due to a decrease in total fluid output (p = 0.05). On multivariable regression, a 10 mL/kg increase in overall fluid balance was associated with an increased risk of developing hyponatremia (OR 1.84 [1.23, 3.45], p = 0.016). No differences in the sodium content of urine, gastric, or bowel bag fluid were observed, and sodium balance was equivalent between cohorts. DISCUSSION Hyponatremia in babies with gastroschisis in the early postnatal period was associated with positive fluid balance and decreased fluid output. Prospective studies to determine the appropriate fluid resuscitation strategy in this population are warranted.
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Chabra S, Peterson SE, Cheng EY. Development of a prenatal clinical care pathway for uncomplicated gastroschisis and literature review. J Neonatal Perinatal Med 2021; 14:75-83. [PMID: 32145003 DOI: 10.3233/npm-190277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Shilpi Chabra
- Department of Pediatrics, Division of Neonatology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Suzanne E Peterson
- Department of Obstetrics/Gynecology, Division of Maternal-Fetal Medicine Swedish Medical Center, Seattle, WA, USA
| | - Edith Y Cheng
- Department of Obstetrics/Gynecology, Division of Maternal-Fetal Medicine, Seattle Children's Hospital and University of Washington Medical Center, Seattle, WA, USA
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Nitzsche K, Fitze G, Rüdiger M, Birdir C. Prenatal Prediction of Outcome by Fetal Gastroschisis in a Tertiary Referral Center. Diagnostics (Basel) 2020; 10:diagnostics10080540. [PMID: 32751744 PMCID: PMC7460378 DOI: 10.3390/diagnostics10080540] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 01/02/2023] Open
Abstract
The aim of this study was to find a prenatal parameter to be able to predict possible prenatal complications or postnatal surgical options, thus allowing the fetal medicine specialist, together with pediatric surgeons and neonatologists, to improve the counseling of the parents and to determine the timing of delivery and therapy. This was a retrospective analysis of prenatal diagnosis and outcome of fetuses with 34 cases of gastroschisis between the years 2007 and 2017. A total of 34 fetuses with gastroschisis were examined and 33 outcomes registered: 22 cases of simple gastroschisis (66.7%) and 11 cases of complex gastroschisis (33.3%). A cut-off value of 18 mm for intraabdominal bowel dilatation (IABD) showed a positive predictive value (PPV) of 100% for predicting simple gastroschisis. IABD gives the best prediction for simple versus complex gastroschisis (cut-off of 18 mm). Extra-abdominal bowel dilatation (EABD) cut-off values of 10 mm and 18 mm showed low sensitivity and specificity to predict complex gastroschisis.
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Affiliation(s)
- Katharina Nitzsche
- Department of Obstetrics and Gynecology, University Clinic of Carl Gustav Carus Dresden, Technische Universität Dresden, 01307 Dresden, Germany;
| | - Guido Fitze
- Department of Pediatric Surgery, University Clinic of Carl Gustav Carus Dresden, Technische Universität Dresden, 01307 Dresden, Germany;
| | - Mario Rüdiger
- Department of Pediatrics, University Clinic of Carl Gustav Carus Dresden, Technische Universität Dresden, 01307 Dresden, Germany;
| | - Cahit Birdir
- Department of Obstetrics and Gynecology, University Clinic of Carl Gustav Carus Dresden, Technische Universität Dresden, 01307 Dresden, Germany;
- Correspondence:
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Lopez A, Benjamin RH, Raut JR, Ramakrishnan A, Mitchell LE, Tsao K, Johnson A, Langlois PH, Swartz MD, Agopian A. Mode of delivery and mortality among neonates with gastroschisis: A population-based cohort in Texas. Paediatr Perinat Epidemiol 2019; 33:204-212. [PMID: 31087678 PMCID: PMC7028334 DOI: 10.1111/ppe.12554] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/11/2019] [Accepted: 03/17/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mode of delivery is hypothesised to influence clinical outcomes among neonates with gastroschisis. Results from previous studies of neonatal mortality have been mixed; however, most studies have been small, clinical cohorts and have not adjusted for potential confounders. OBJECTIVES To evaluate whether caesarean delivery is associated with mortality among neonates with gastroschisis. METHODS We studied liveborn, nonsyndromic neonates with gastroschisis delivered during 1999-2014 using data from the Texas Birth Defect Registry. Using multivariable Cox proportional hazards regression, we separately assessed the relationship between caesarean and death during two different time periods, prior to 29 days (<29 days) and prior to 365 days (<365 days) after delivery, adjusting for potential confounders. We also updated a recent meta-analysis on this relationship, combining our estimates with those from the literature. RESULTS Among 2925 neonates with gastroschisis, 63% were delivered by caesarean. No associations were observed between caesarean delivery and death <29 days (adjusted hazard ratio [aHR] 1.00, 95% confidence interval [CI] 0.63, 1.61) or <365 days after delivery (aHR 0.99, 95% CI 0.70, 1.41). The results were similar among those with additional malformations and among those without additional malformations. When we combined our estimate with prior estimates from the literature, results were similar (combined risk ratio [RR] 1.00, 95% CI 0.84, 1.19). CONCLUSIONS Although caesarean rates among neonates with gastroschisis were high, our results suggest that mode of delivery is not associated with mortality among these individuals. However, data on morbidity outcomes (eg intestinal damage, infection) were not available in this study.
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Affiliation(s)
- Adriana Lopez
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, Texas
| | - Renata H. Benjamin
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, Texas
| | - Janhavi R. Raut
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, Texas
| | - Anushuya Ramakrishnan
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, Texas
| | - Laura E. Mitchell
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, Texas
| | - Kuojen Tsao
- Center for Surgical Trials and Evidence-based Practice (CSTEP), Department of Pediatric Surgery at McGovern Medical School at UTHealth at Houston and Children’s Memorial Hermann Hospital, Houston, Texas
| | - Anthony Johnson
- Departments of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at UTHealth, Houston, Texas and Pediatric Surgery, UTHealth and The Fetal Center at Children’s Memorial Hermann Hospital, Houston, Texas
| | - Peter H. Langlois
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas
| | - Michael D. Swartz
- Department of Biostatistics and Data Science, UTHealth School of Public Health, Houston, Texas
| | - A.J. Agopian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, Texas
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Brebner A, Czuzoj-Shulman N, Abenhaim HA. Prevalence and predictors of mortality in gastroschisis: a population-based study of 4803 cases in the USA. J Matern Fetal Neonatal Med 2018; 33:1725-1731. [PMID: 30477359 DOI: 10.1080/14767058.2018.1529163] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Purpose: Gastroschisis is a rare congenital anomaly consisting of an abdominal wall defect resulting in extrusion of the abnormal organs. Survival of these infants exceeds 90%. Few large-scale studies have examined the predictors of mortality for these infants. Our objective was to conduct a population-based study to determine prevalence and predictors of mortality among infants born with gastroschisis.Materials and methods: We used the "Period Linked Birth-Infant Death" database to create a cohort of all births occurring between 2009 and 2013. Infants were categorized by the presence of gastroschisis, excluding infants born at <24-week gestation. Baseline maternal and newborn characteristics were compared for infants who survived and those who died. Multivariate logistic regression models were used to estimate the effect of maternal and fetal factors on mortality, while adjusting for appropriate baseline characteristics.Results: There were 4803 cases of gastroschisis, with 287 deaths. The prevalence of gastroschisis increased from 2.04 to 2.49/10,000 births over the study period. The rate of death stayed constant at about 5.9%. We found that 38.1% of these infants died on day 0 of life. Statistically significant predictors of mortality were the presence of an additional congenital anomaly, birth weight <2500 g, prepregnancy diabetes, gestational age <34 weeks, paying out of pocket for healthcare, and maternal obesity.Conclusions: The prevalence of gastroschisis in the USA increased, yet the mortality rate remained stable. Infants born preterm <34 weeks, with birth weights <2500 g, or with an additional congenital anomaly were at the highest risk of death.
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Affiliation(s)
- Alison Brebner
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Nicholas Czuzoj-Shulman
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, QC, Canada
| | - Haim Arie Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, QC, Canada.,Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, QC, Canada
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Osmundo Junior GDS, Mohamed SHM, Nishie EN, Tannuri ACA, Gibelli MABC, Francisco RPV, Brizot MDL. Association of spontaneous labor onset with neonatal outcomes in pregnancies with fetal gastroschisis: A retrospective cohort analysis. Acta Obstet Gynecol Scand 2018; 98:154-161. [PMID: 30264855 DOI: 10.1111/aogs.13473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 09/21/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The present study aims to investigate the association of spontaneous labor onset with neonatal outcomes in pregnancies with fetal gastroschisis. The secondary goal was to evaluate the association between ultrasound markers and labor onset in pregnancies with fetal gastroschisis. MATERIAL AND METHODS A retrospective analysis was performed for 207 pregnancies with fetal gastroschisis between 2005 and 2017. Patients were followed according to a strict protocol involving ultrasound scans and routine evaluations of fetal biophysical profile parameters and intra- and extra-abdominal bowel diameters. Labor, delivery and neonatal records were reviewed. The neonatal outcomes were complex gastroschisis, staged surgical closure of the abdominal defect, short bowel syndrome, time on mechanical ventilation, time to full enteral feeding and necrotizing enterocolitis. RESULTS Spontaneous labor onset was associated with complex gastroschisis (30.7% vs 6.8%, P = 0.002) and short bowel syndrome (13.2% vs none, P = 0.013) in cases with spontaneous preterm delivery compared with the indicated preterm deliveries. Spontaneous labor onset was associated with a longer time on mechanical ventilation for term and preterm newborns. Associations were not observed between ultrasound markers and spontaneous labor onset. CONCLUSIONS Spontaneous labor onset in pregnancies with fetal gastroschisis was associated with adverse neonatal outcomes, particularly in those born preterm.
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Affiliation(s)
| | | | - Estela Naomi Nishie
- Department of Obstetrics and Gynecology, Hospital das Clínicas, São Paulo University Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Division of Pediatric Surgery, Department of Pediatrics, São Paulo University Medical School, Sao Paulo, Brazil
| | - Maria Augusta Bento Cicaroni Gibelli
- Division of Neonatology, Department of Pediatrics, Hospital das Clínicas, São Paulo University Medical School, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Maria de Lourdes Brizot
- Department of Obstetrics and Gynecology, Hospital das Clínicas, São Paulo University Medical School, Sao Paulo, Brazil
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Melov SJ, Tsang I, Cohen R, Badawi N, Walker K, Soundappan SSV, Alahakoon TI. Complexity of gastroschisis predicts outcome: epidemiology and experience in an Australian tertiary centre. BMC Pregnancy Childbirth 2018; 18:222. [PMID: 29890949 PMCID: PMC5996507 DOI: 10.1186/s12884-018-1867-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/30/2018] [Indexed: 01/18/2023] Open
Abstract
Background Gastroschisis is a congenital anomaly of the fetal abdominal wall, usually to the right side of umbilical insertion. It is often detected by routine antenatal ultrasound. Significant maternal and pediatric resources are utilised in the care of women and infants with gastroschisis. Increasing rates of gastroschisis worldwide have led institutions to review local data and investigate outcomes. A collaborative project was developed to review local epidemiology and investigate antenatal and neonatal factors influencing hospital length of stay (LOS) and total parental nutrition (TPN) in infants born with gastroschisis. Methods We performed a five-year review of infants born with gastroschisis (2011–2015) at a major Australian centre. Complex gastroschisis was defined as involvement of stenosis, atresia, ischemia, volvulus or perforation and closed or vanishing gastroschisis. We extracted data from files and databases at the two participating hospitals, a major maternal fetal medicine centre and the affiliated children’s hospital. Results There were 56 infants antenatally diagnosed with gastroschisis with no terminations, one stillbirth (2%) and one infant with ‘vanishing’ gastroschisis. The mean maternal age was 23.9 years (range, 15–39 years). The mean gestation at delivery was 36 weeks (range, 25–39+ 3 weeks). Of the 55 neonates who received surgical management, 62% had primary closure. The median LOS was 33 (IQR, 23–45) days and the median duration of TPN was 26 (IQR, 17–36) days. Longer days on TPN (median 35 vs 16 days, P = 0.03) was associated with antenatal finding of multiple dilated bowel loops. Postnatal diagnosis of complex gastroschisis was made in 16% of cases and was associated with both longer LOS (median 89 vs 30 days, P = 0.003) and days on TPN (median 46 vs 21 days, P = 0.009). Conclusion Complex gastroschisis was associated with greater days on TPN and LOS. We found no late-gestation stillbirths and a low overall rate of 1.8%, suggesting the risk for stillbirth associated with gastroschisis is lower than previously documented. This information may assist counselling families. Improved data collection worldwide may reveal causative factors and enable antenatal outcome predictors.
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Affiliation(s)
- Sarah J Melov
- Westmead Institute for Maternal and Fetal Medicine, Women's and Newborn Health, Westmead Hospital, Research & Education Network Building, Hawkesbury Rd, PO Box 533, Westmead, NSW, 2145, Australia.
| | - Irene Tsang
- Department of Paediatric Surgery, The Children's Hospital at Westmead, The Sydney Children's Hospital Network, Hawkesbury Rd, Westmead, NSW, 2145, Australia
| | - Ralph Cohen
- Department of Paediatric Surgery, The Children's Hospital at Westmead, The Sydney Children's Hospital Network, Hawkesbury Rd, Westmead, NSW, 2145, Australia.,The University of Sydney, Sydney, NSW, Australia
| | - Nadia Badawi
- Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, The Sydney Children's Hospital Network, Hawkesbury Rd, Westmead, Wentworthville, NSW, 2145, Australia.,The University of Sydney, Sydney, NSW, Australia.,Cerebral Palsy Alliance Research Institute, Sydney, NSW, Australia
| | - Karen Walker
- Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, The Sydney Children's Hospital Network, Hawkesbury Rd, Westmead, Wentworthville, NSW, 2145, Australia.,The University of Sydney, Sydney, NSW, Australia.,Cerebral Palsy Alliance Research Institute, Sydney, NSW, Australia
| | - Soundappan S V Soundappan
- Department of Paediatric Surgery, The Children's Hospital at Westmead, The Sydney Children's Hospital Network, Hawkesbury Rd, Westmead, NSW, 2145, Australia.,The University of Sydney, Sydney, NSW, Australia
| | - Thushari I Alahakoon
- Westmead Institute for Maternal and Fetal Medicine, Women's and Newborn Health, Westmead Hospital, Research & Education Network Building, Hawkesbury Rd, PO Box 533, Westmead, NSW, 2145, Australia.,The University of Sydney, Sydney, NSW, Australia
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11
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Early elective delivery for fetal ventriculomegaly: are neurosurgical and medical complications mitigated by this practice? Childs Nerv Syst 2018; 34:829-835. [PMID: 29196812 DOI: 10.1007/s00381-017-3662-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 11/10/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Antenatally diagnosed ventriculomegaly (VM) requires the balance of risks of neurological injury with premature delivery. The purpose of this study was to evaluate outcomes related to early elective delivery due to fetal VM at our institution. METHODS We retrospectively assessed 120 babies (2008-2012) with antenatally diagnosed fetal VM. Inclusion criteria for ("early") cohort were (1) elective delivery occurred for expedited neurosurgical intervention between 32 and 36 weeks EGA and (2) fetal VM noted on official antenatal ultrasound. The comparative "near term" cohort differed only in that delivery occurred at 37+ weeks EGA. Statistical significance for comparative analyses set a priori at p < 0.05. RESULTS Babies electively delivered early had a lower birthweight (p < 0.0001), greater ventricle width (p < 0.0001), and underwent initial CSF diversion sooner (p = 0.014). The early cohort (n = 22), compared to near term (n = 50), had a lower birthweight (p < 0.0001), greater ventricle width (p < 0.0001), and underwent initial CSF diversion sooner (p = 0.014). The early cohort required more repeat procedures: (45 vs. 22% p = 0.021), and VPS removals after VPS infections (41 vs. 12%, p = 0.010). Additionally, newborn respiratory failure (32 vs. 6%, p = 0.037) was more common. Finally, of four babies who died in the early cohort, 2/4 died for prematurity-associated pulmonary hypoplasia. CONCLUSIONS While early elective delivery for fetal VM expedites intervention for rapidly expanding ventricles, few benefits were identified. Our study concluded those infants that were delivered earlier had increased VPS infections, repeat neurosurgical procedures, and medical co-morbidities. A multi-institutional prospective observational study would be needed in order to confirm the clinical implications of such practice.
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Haddock C, Skarsgard ED. Understanding gastroschisis and its clinical management: where are we? Expert Rev Gastroenterol Hepatol 2018; 12:405-415. [PMID: 29419329 DOI: 10.1080/17474124.2018.1438890] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Gastroschisis is the commonest developmental defect of the anterior abdominal wall in both developed and developing countries. The past 30 years have seen transformational improvements in outcome due to advances in neonatal intensive care and enhanced integration between the disciplines of maternal fetal medicine, neonatology and pediatric surgery. A review of gastroschisis, which emphasizes its epidemiology, multidisciplinary care strategies and contemporary outcomes is timely. Areas covered: This review discusses the current state of knowledge related to prevalence and causation, and postulated embryopathologic mechanisms contributing to the development of gastroschisis. Using relevant, current literature with an emphasis on high level evidence where it exists, we review modern techniques of prenatal diagnosis, pre and postnatal risk stratification, preferred timing and method of delivery, options for abdominal wall closure, nutritional management, and short and long term clinical and neurodevelopmental follow-up. Expert commentary: This section explores controversies in contemporary management which contribute to practice and cost variation and discusses the benefits of novel nutritional therapies and care standardization that target unnecessary practice variation and improve overall cost-effectiveness of gastroschisis care. The commentary concludes with a review of fertile areas of gastroschisis research, which represent opportunities for knowledge synthesis and further outcome improvement.
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Affiliation(s)
- Candace Haddock
- a Department of Surgery , British Columbia Children's Hospital , Vancouver , Canada
| | - Erik D Skarsgard
- a Department of Surgery , British Columbia Children's Hospital , Vancouver , Canada
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Landisch RM, Yin Z, Christensen M, Szabo A, Wagner AJ. Outcomes of gastroschisis early delivery: A systematic review and meta-analysis. J Pediatr Surg 2017; 52:1962-1971. [PMID: 28947324 DOI: 10.1016/j.jpedsurg.2017.08.068] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/28/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Elective preterm delivery (EPD) of a fetus with gastroschisis may prevent demise and ameliorate intestinal injury. While the literature on optimal timing of delivery varies, we hypothesize that a potential benefit may be found with EPD. METHODS A meta-analysis of publications describing timing of delivery in gastroschisis from 1/1990 to 8/2016 was performed, including studies where either elective preterm delivery (group 1, G1) or preterm gestational age (GA) (group 2, G2) were evaluated against respective comparators. The following outcomes were analyzed: total parenteral nutrition (TPN), first enteral feeding (FF), length of stay, ventilator days, fetal demise, complex gastroschisis, sepsis, and death. RESULTS Eighteen studies describing 1430 gastroschisis patients were identified. G1 studies found less sepsis (p<0.01), fewer days to FF (p=0.03), and 11days less of TPN (p=0.07) in the preterm cohort. Comparatively, G2 studies showed less days to FF in term GA (p=0.02).Whereas G1 BWs were similar, G2 preterm had a significantly lower BW compared to controls (p=0.001). CONCLUSIONS Elective preterm delivery appears favorable with respect to feeding and sepsis. However, benefits are lost when age is used as a surrogate of EPD. A randomized, prospective, multi-institutional trial is necessary to delineate whether EPD is advantageous to neonates with gastroschisis. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Rachel M Landisch
- Division of Pediatric Surgery, Department of Surgery, The Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Ziyan Yin
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Melissa Christensen
- Division of Pediatric Surgery, Department of Surgery, The Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aniko Szabo
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amy J Wagner
- Division of Pediatric Surgery, Department of Surgery, The Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
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Briganti V, Luvero D, Gulia C, Piergentili R, Zaami S, Buffone EL, Vallone C, Angioli R, Giorlandino C, Signore F. A novel approach in the treatment of neonatal gastroschisis: a review of the literature and a single-center experience. J Matern Fetal Neonatal Med 2017; 31:1234-1240. [PMID: 28337935 DOI: 10.1080/14767058.2017.1311859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Gastroschisis is a congenital abdominal wall defect and its management remains an issue. We performed a review of the literature to summarize its evaluation, management and outcome and we describe a new type of surgical reduction performed in our center without anesthesia (GA), immediately after birth, in the delivery room. Between January 2002 and March 2013, we enrolled all live born infants with gastroschisis referred to the third-level Division of Obstetrics and Gynecology "San Camillo" of Rome. Two groups of infants were identified: group 1 in which gastroschis reduction was performed by the traditional technique and group 2 in which reduction was immediately performed after birth in the delivery room without GA. Twelve infants were enrolled in group 1, and seven infants in group 2. Statistical significance was observed between the groups regarding the hospital stay, for the duration of parenteral nutrition and full oral feeds (p = .004). Survival was similar between two groups. The reduction without GA performed immediately after birth in a delivery room encourages the relationship between the mother and her child and appears to be a safe and feasible technique in a selected group of patients with simple gastroschisis defect; for this reason, it could represent a valid alternative to traditional approach.
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Affiliation(s)
- Vito Briganti
- a Department of Pediatric Surgery and Urology , Azienda Ospedaliera San Camillo-Forlanini , Rome , Italy
| | - Daniela Luvero
- b Department of Medicine, Unit of Gynaecology and Obstetrics , Università Campus Bio-Medico di Roma , Rome , Italy
| | - Caterina Gulia
- c Department of Urologic and Gynaecologic Sciences , Policlinico Umberto I, Sapienza - University of Rome , Italy
| | - Roberto Piergentili
- d Institute of Molecular Biology and Pathology, National Research Council , Department of Biology and Biotechnologies , Sapienza - University of Rome , Italy
| | - Simona Zaami
- e Department of Anatomical, Histological Forensic and Orthopaedic Sciences , Sapienza - University of Rome , Italy
| | - Elsa Laura Buffone
- f Department of Neonatal Intensive Care , Azienda Ospedaliera San Camillo-Forlanini , Rome , Italy
| | - Cristina Vallone
- g Department of Gynaecology , Azienda Ospedaliera San Camillo-Forlanini , Rome , Italy
| | - Roberto Angioli
- b Department of Medicine, Unit of Gynaecology and Obstetrics , Università Campus Bio-Medico di Roma , Rome , Italy
| | - Claudio Giorlandino
- h Department of Obstetrics and Gynecology , Altamedica Main Center , Rome , Italy
| | - Fabrizio Signore
- g Department of Gynaecology , Azienda Ospedaliera San Camillo-Forlanini , Rome , Italy
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Abstract
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.
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Tosello B, Zahed M, Guimond F, Baumstarck K, Faure A, Michel F, Claris O, Gire C, Berakdar I, Massardier J, D’Ercole C, Merrot T. Management and outcome challenges in newborns with gastroschisis: A 6-year retrospective French study. J Matern Fetal Neonatal Med 2016; 30:2864-2870. [DOI: 10.1080/14767058.2016.1265935] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Barthelemy Tosello
- Department of Neonatology, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Meriem Zahed
- Self-Perceived Health Assessment Research Unit, Aix-Marseille University, Marseille, France
| | - Floriane Guimond
- Department of Neonatology, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Karine Baumstarck
- Self-Perceived Health Assessment Research Unit, Aix-Marseille University, Marseille, France
| | - Alice Faure
- Department of Pediatric Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Fabrice Michel
- Pediatric Intensive Care Unit, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Olivier Claris
- Department of Neonatology, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Catherine Gire
- Department of Neonatology, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Isabelle Berakdar
- Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Jerome Massardier
- Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Claude D’Ercole
- Department of Obstetrics and Gynecology, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Thierry Merrot
- Department of Pediatric Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
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Abstract
PURPOSE OF REVIEW The diagnosis and treatment of gastroschisis spans the perinatal disciplines of maternal fetal medicine, neonatology, and pediatric surgery. Since gastroschisis is one of the commonest and costliest structural birth defects treated in neonatal ICUs, a comprehensive review of its epidemiology, prenatal diagnosis, postnatal treatment, and short and long-term outcomes is both timely and relevant. RECENT FINDINGS The incidence of gastroschisis has increased dramatically over the past 20 years, leading to a renewed interest in causation. The widespread availability of maternal screening and ultrasound results in very high rates of prenatal diagnosis, which enables evaluation of the optimal timing and mode of delivery. The preferred method of surgical closure continues to be an issue of debate among pediatric surgeons, whereas postsurgical treatment seeks to expedite the initiation and progression of enteral feeding and minimize complications. A small subset of babies with complex gastroschisis leading to intestinal failure benefit from the knowledge and expertise of dedicated interdisciplinary teams, which seek to bring novel therapies and improved clinical outcomes. SUMMARY The opportunities to increase the knowledge of causation, and identify best practices leading to improved outcomes, drive the ongoing need for collaborative clinical research in gastroschisis.
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Outcomes in infants with prenatally diagnosed gastroschisis and planned preterm delivery. Pediatr Surg Int 2015; 31:1047-53. [PMID: 26399421 DOI: 10.1007/s00383-015-3795-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND The timing and mode of delivery of pregnancies with prenatally diagnosed gastroschisis remains controversial. AIM To evaluate the outcome of patients with gastroschisis managed during two time periods: 2006-2009 and 2010-2014, with planned elective cesarean delivery at 37 versus 35 gestational weeks (gw). A secondary aim was to analyze the outcome in relation to the gestational age at birth. MATERIAL AND METHODS Retrospective review of all cases with gastroschisis managed at our institution between 2006 and 2014. RESULTS Fifty-two patients were identified, 24 during the initial period, and 28 during the second. There were a significantly higher number of emergency cesarean deliveries in the first period. There were no differences between groups with regard to the use of preformed silo, need of parenteral nutrition or length of hospital stay. When analyzing the outcome in relation to the gw the patients actually were born, we observed that patients delivered between 35 and 36.9 gw were primary closed in 88.5% of cases, with shorter time on mechanical ventilation, parenteral nutrition and hospital stay. CONCLUSION Planned caesarian section at 35 completed gestational weeks for fetuses with prenatally diagnosed gastroschisis is safe. We observe the best outcome for patients born between 35 and 36.9 gw.
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Al-Kaff A, MacDonald SC, Kent N, Burrows J, Skarsgard ED, Hutcheon JA. Delivery planning for pregnancies with gastroschisis: findings from a prospective national registry. Am J Obstet Gynecol 2015; 213:557.e1-8. [PMID: 26116872 DOI: 10.1016/j.ajog.2015.06.048] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 05/13/2015] [Accepted: 06/17/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the influence of planned mode and planned timing of delivery on neonatal outcomes in infants with gastroschisis. STUDY DESIGN Data from the Canadian Pediatric Surgery Network cohort were used to identify 519 fetuses with isolated gastroschisis who were delivered at all tertiary-level perinatal centers in Canada from 2005-2013 (n = 16). Neonatal outcomes (including length of stay, duration of total parenteral nutrition, and a composite of perinatal death or prolonged exclusive total parenteral nutrition) were compared according to the 32-week gestation planned mode and timing of delivery with the use of the multivariable quantile and logistic regression. RESULTS Planned induction of labor was not associated with decreased length of stay (adjusted median difference, -2.6 days; 95% confidence interval [CI], -9.9 to 4.8), total parenteral nutrition duration (adjusted median difference, -0.2 days; 95% CI, -6.4 to 6.0), or risk of the composite adverse outcome (relative risk, 1.7; 95% CI, 0.1-3.2) compared with planned vaginal delivery after spontaneous onset of labor. Planned delivery at 36-37 weeks' gestation was not associated with decreased length of stay (adjusted median difference, 5.9 days; 95% CI, -5.7 to 17.5), total parenteral nutrition duration (adjusted median difference, 3.2 days; 95% CI, -7.9 to 14.3), or risk of composite outcome (relative risk, 2.3; 95% CI, 0.8-5.4) compared with planned delivery at ≥38 weeks' gestation. CONCLUSION Infants with gastroschisis who were delivered after planned induction or planned delivery at 36-37 weeks' gestation did not have significantly better neonatal outcomes than planned vaginal delivery after spontaneous onset of labor and planned delivery at ≥38 weeks' gestation.
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Harper LM, Goetzinger KR, Biggio JR, Macones GA. Timing of elective delivery in gastroschisis: a decision and cost-effectiveness analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:227-32. [PMID: 25377308 PMCID: PMC4861040 DOI: 10.1002/uog.14721] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/21/2014] [Accepted: 10/27/2014] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To determine the most cost-effective timing of delivery in pregnancies complicated by gastroschisis, using a decision-analytic model. METHODS We created a decision-analytic model to compare planned delivery at 35, 36, 37, 38 and 39 weeks' gestation. Outcomes considered were stillbirth, death within 1 year of birth and respiratory distress syndrome (RDS). Probability estimates of events (stillbirth, complex gastroschisis and RDS for each gestational age at delivery and risk of death with simple and complex gastroschisis), utilities and costs assigned to the outcomes were obtained from the published literature. Cost analysis was assessed from a societal perspective, using a willingness-to-pay threshold of $100,000 per surviving infant. Outcomes and costs were considered throughout 1 year of postnatal life. Multiway sensitivity analysis was performed to address uncertainties in baseline assumptions. RESULTS In the base-case analysis, delivery at 38 weeks' gestation was the most cost-effective strategy. Planned delivery at 35 weeks was associated with the fewest stillbirths and deaths within 1 year of delivery, owing largely to a lower ongoing risk of stillbirth. In Monte Carlo simulation when every variable was varied over its entire range, delivery at 38 weeks was cost-effective compared to delivery at 39 weeks in 76% of trials and delivery at 37 weeks was cost-effective in 69% of trials. Delivery at 38 weeks resulted in three additional cases of RDS for every 100 stillbirths or deaths within 1 year that were prevented. CONCLUSIONS For pregnancies complicated by gastroschisis, the most cost-effective timing of delivery is at 38 weeks. Few additional cases of RDS are caused for every one stillbirth or death within 1 year that was prevented with delivery at 37-38 weeks compared with at 39 weeks.
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Affiliation(s)
- Lorie M. Harper
- The Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, AL
| | - Katherine R. Goetzinger
- The Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Joseph R. Biggio
- The Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health at the University of Alabama at Birmingham, Birmingham, AL
| | - George A. Macones
- The Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
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Youssef F, Laberge JM, Baird RJ. The correlation between the time spent in utero and the severity of bowel matting in newborns with gastroschisis. J Pediatr Surg 2015; 50:755-9. [PMID: 25783374 DOI: 10.1016/j.jpedsurg.2015.02.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 02/13/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Optimal timing of delivery in fetuses with gastroschisis (GS) is unknown. Some favor early induced delivery to prevent bowel injury. This study evaluates the correlation between bowel injury and the gestational age at birth using the Gastroschisis Prognostic Score (GPS). METHODS A national database was analyzed from 2005 to 2013. Patients were pooled based on their gestational age at birth. The mean GPS and % of patients with severe bowel matting were tabulated for each week in utero. Regression modeling was used to evaluate the relationship between the dependent (severe matting and GPS) and independent (gestational age) variables and the R(2) coefficient of determination was derived to evaluate model strength. Additional factors influencing the timing of delivery were evaluated. RESULTS Of 780 cases, 88 were excluded because of missing data. A linear relationship is seen between increasing gestational age and decreasing bowel matting (R(2)=0.66) and GPS (R(2)=0.72). For every week in utero, the % of patients with severe matting decreases by 3.6%. CONCLUSION Early induced delivery simply to protect the bowel from ongoing in utero damage appears unfounded and should be reserved for evidence of closing gastroschisis or traditional obstetrical/fetal indications.
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Affiliation(s)
- Fouad Youssef
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean Martin Laberge
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Robert J Baird
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada.
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Brown N, Nardi M, Greer RM, Petersen S, Thomas J, Gardener G, Cincotta R, Kumar S. Prenatal extra-abdominal bowel dilatation is a risk factor for intrapartum fetal compromise for fetuses with gastroschisis. Prenat Diagn 2015; 35:529-33. [DOI: 10.1002/pd.4535] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/30/2014] [Accepted: 11/08/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Nicole Brown
- Mater Centre for Maternal Fetal Medicine; Mater Mothers' Hospital; South Brisbane Queensland Australia
| | - Mel Nardi
- Mater Centre for Maternal Fetal Medicine; Mater Mothers' Hospital; South Brisbane Queensland Australia
| | - Ristan M. Greer
- Mater Research Institute/University of Queensland; South Brisbane Queensland Australia
| | - Scott Petersen
- Mater Research Institute/University of Queensland; South Brisbane Queensland Australia
- Mater Centre for Maternal Fetal Medicine; Mater Mothers' Hospital; South Brisbane Queensland Australia
| | - Joseph Thomas
- Mater Research Institute/University of Queensland; South Brisbane Queensland Australia
- Mater Centre for Maternal Fetal Medicine; Mater Mothers' Hospital; South Brisbane Queensland Australia
| | - Glenn Gardener
- Mater Research Institute/University of Queensland; South Brisbane Queensland Australia
- Mater Centre for Maternal Fetal Medicine; Mater Mothers' Hospital; South Brisbane Queensland Australia
| | - Robert Cincotta
- Mater Research Institute/University of Queensland; South Brisbane Queensland Australia
- Mater Centre for Maternal Fetal Medicine; Mater Mothers' Hospital; South Brisbane Queensland Australia
| | - Sailesh Kumar
- Mater Research Institute/University of Queensland; South Brisbane Queensland Australia
- Mater Centre for Maternal Fetal Medicine; Mater Mothers' Hospital; South Brisbane Queensland Australia
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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.
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Gamba P, Midrio P. Abdominal wall defects: prenatal diagnosis, newborn management, and long-term outcomes. Semin Pediatr Surg 2014; 23:283-90. [PMID: 25459013 DOI: 10.1053/j.sempedsurg.2014.09.009] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Omphalocele and gastroschisis represent the most frequent congenital abdominal wall defects a pediatric surgeon is called to treat. There has been an increased reported incidence in the past 10 years mainly due to the diffuse use of prenatal ultrasound. The early detection of these malformations, and related associated anomalies, allows a multidisciplinary counseling and planning of delivery in a center equipped with high-risk pregnancy assistance, pediatric surgery, and neonatology. At present times, closure of defects, even in multiple stages, is always possible as well as management of most of cardiac-, urinary-, and gastrointestinal-associated malformations. The progress, herein discussed, in the care of newborns with abdominal wall defects assures most of them survive and reach adulthood. Some aspects of transition of medical care will also be considered, including fertility and cosmesis.
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Affiliation(s)
- Piergiorgio Gamba
- Pediatric Surgery, Department of Woman and Child Health, University Hospital, Via Giustiniani 3, Padua 35121, Italy.
| | - Paola Midrio
- Pediatric Surgery, Department of Woman and Child Health, University Hospital, Via Giustiniani 3, Padua 35121, Italy
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Delivery room surgery: an applicable therapeutic strategy for gastroschisis in developing countries. World J Pediatr 2014; 10:69-73. [PMID: 24464667 DOI: 10.1007/s12519-014-0455-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 05/13/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The survival rate of infants with gastroschisis has improved significantly. It is over 90% in developed countries, but 50% in developing countries. This study aimed to investigate the factors improving the survival rate of infants with gastroschisis in developing countries. METHODS Neonates meeting the inclusion criteria, who presented to our center since the establishment of delivery room surgery, were enrolled into this retrospective study. Data were evaluated specifically to determine the role of delivery room surgery in reducing the mortality and morbidity of infants with gastroschisis and to identify factors optimizing the conditions of outborn infants. RESULTS A total of 64 infants were identified. The overall survival rate of the infants was 60.9%. The survival rate of infants in inborns was 76.5%, and the survival rate of infants in outborns was 43.3%. Infants of the outborn group took more time to reach full enteral feeding, and were more likely to require a prolonged stay in hospital when compared with those of the inborn group. Logistic analysis identified that the surgical technique, the presence of sepsis and intestinal necrosis could be expected to influence the outcome of gastroschisis. CONCLUSIONS The strategy of delivery of patients in a center prepared to perform delivery room closure of gastroschisis appears to improve the survival of patients with gastroschisis. Further reduction in mortality rates will depend on improved conditions of outborn infants.
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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.
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Affiliation(s)
- Karine Lepigeon
- Materno-fetal & Obstetrics Research Unit, Department of Obstetrics and Gynecology, University Hospital, 1011, Lausanne, Switzerland
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Abstract
Congenital birth defects and early/premature birth are common complex conditions affecting populations throughout the world, the interaction of which accounts for a significant proportion of neonatal morbidity and mortality. The relationship between these two conditions is not well understood. Several congenital birth defects can directly lead to early delivery. In addition, certain fetal conditions may necessitate early or premature delivery, several of which are also associated with maternal conditions necessitating early birth. Further understanding of both the incidences and causes of congenital birth defects and of early and premature birth will facilitate establishment of strategies to improve neonatal mortality and morbidity.
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Affiliation(s)
- Jonathan R Swanson
- Department of Pediatrics, University of Virginia Children's Hospital, University of Virginia, Box 800386, Charlottesville, VA 22908, USA
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Nasr A, Wayne C, Bass J, Ryan G, Langer JC. Effect of delivery approach on outcomes in fetuses with gastroschisis. J Pediatr Surg 2013; 48:2251-5. [PMID: 24210195 DOI: 10.1016/j.jpedsurg.2013.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 07/04/2013] [Accepted: 07/05/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND/PURPOSE There is considerable controversy regarding optimal mode and timing of delivery for fetuses with gastroschisis. Our objectives were to describe the variation in institutional approach regarding these factors, and to evaluate the effect of timing of delivery on outcomes in fetuses with gastroschesis. METHODS Members of the maternal-fetal medicine community across Canada were surveyed regarding their personal and institutional approach of delivery. Data from the Canadian Pediatric Surgery Network (CAPSnet) were analyzed. RESULTS The survey showed significant variability in delivery approach between institutions, although no center routinely performs cesarean section. Infants delivered vaginally (VD) were categorized into three groups: Group 1, VD <36 weeks (n=114); Group 2, VD 36-37 weeks (n=218); and Group 3, VD ≥38 weeks (n=75). Score of Neonatal Acute Physiology, complication rates, length of time on total parenteral nutrition (TPN), and length of hospital stay (LOS) were higher in Group 1; bowel matting was greater in Group 3. There were no differences between the groups regarding other complications. CONCLUSIONS Our data suggest that preterm delivery was associated with more complications, longer time on TPN, and longer LOS; delivery ≥38 weeks was associated with increased bowel matting. These outcomes should be considered when determining institutional protocol.
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Affiliation(s)
- Ahmed Nasr
- Department of Surgery, Children's Hospital of Eastern Ontario. University of Ottawa, Ottawa, Ontario, Canada.
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Al-Shanafey SN, Fontecha CG, Canyadell MA, Soldado FC, Rojo AA, Conesa XJ, Toran NT, Ibanez VM, Peiro JL. Reduction in neural injury with earlier delivery in a mouse model of congenital myelomeningocele: laboratory investigation. J Neurosurg Pediatr 2013; 12:390-4. [PMID: 23931768 DOI: 10.3171/2013.7.peds1351] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors undertook this study to assess the effect of preterm delivery with respect to neural protection in a congenital myelomeningocele (MMC) mouse model. METHODS After confirmation of pregnancy in 15 female mice, a congenital MMC model was produced by administration of retinoic acid on the 7th day of gestation. The pregnant mice underwent cesarean sections on Days 15 (n = 5, Group E15), 17 (n = 5, Group E17), and 19 (n = 5, Group E19). Histological analyses were conducted on the lumbar defect and on the craniocervical junction in all fetuses with MMC. RESULTS Fetuses in Group E19 showed the most significant injury to neural tissue of the spinal cord at the MMC area followed by those in Group E17, with Group E15 being the least affected. All groups exhibited a degree of Chiari malformation; Group E19 was the most affected, followed by Group E17, and Group E15 was the least affected. CONCLUSIONS Development of both Chiari malformation and exposed spinal cord injury are progressive during gestation. Preterm delivery in this mouse model of congenital MMC may minimize the degree of injury to the spinal cord neural tissue and the degree of Chiari malformation.
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Affiliation(s)
- Saud N Al-Shanafey
- Bioengineering, Orthopedics, and Pediatric Surgery Laboratory, Institute of Research
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Abstract
OBJECTIVE To estimate obstetric and neonatal outcomes after induction of labor at 37 weeks of gestation compared with expectant management in pregnancies complicated by fetal gastroschisis. METHODS The management of 296 pregnancies involving fetal gastroschisis (1980-2011) was reviewed from a single perinatal center. Ultrasound surveillance and nonstress testing were performed every 2 weeks from 30 weeks of gestation, weekly from 34 weeks of gestation, and twice weekly after 35 weeks of gestation until delivery. Labor was induced if fetal well-being testing was abnormal and, since 1994, labor was routinely induced at 37 weeks of gestation. RESULTS Of 153 pregnancies reaching 37 weeks of gestation, labor was induced in 77 (26%) and 76 (25.7%) were allowed to labor spontaneously. There were no significant differences in mean maternal age (22 years in both), parity (56% compared with 66% nulliparous), presence of other fetal anomalies (12% compared with 9%), cesarean delivery rate (20% in both), 5-minute Apgar score less than 7 (10% compared with 12%), meconium at birth (36% compared with 49%), or respiratory distress syndrome (16% compared with 7%) between the induced and expectantly managed groups. However, neonatal sepsis (25% compared with 42%; P=.02) and a composite outcome of neonatal death and bowel damage (necrosis, atresia, perforation, adhesion; 8% compared with 21%; P=.02) were more common in expectantly managed pregnancies. Moreover, time to oral feeds (-3.4 days), time on total parenteral nutrition (-6.2 days), and hospital stay (-6.7 days) were reduced when labor was induced. CONCLUSION In fetuses with gastroschisis, induction of labor at 37 weeks of gestation was associated with reduced risks of sepsis, bowel damage, and neonatal death compared with pregnancies managed expectantly beyond 37 weeks of gestation. LEVEL OF EVIDENCE II.
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Abstract
BACKGROUND Gastroschisis is an uncommon congenital defect of the anterior abdominal wall that results in herniation of intestinal loops outside the abdominal cavity. Babies with gastroschisis generally do well, but there remains a mortality rate of 5% to 10% and some require prolonged parenteral nutrition and intensive care. Significant injury to the exposed bowel may occur in-utero, and earlier birth may reduce this, improve long-term outcomes and reduce complications, such as necrotising enterocolitis. However, it may also increase complications related to prematurity. There is a lack of published data in this area. OBJECTIVES To assess the effects of elective preterm birth for fetal gastroschisis in pregnancies complicated by this condition. The mode of birth may be either vaginal or by caesarean section, but this review is studying only timing, not the route, of birth. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (16 January 2013). SELECTION CRITERIA Individual patient randomised controlled trials of planned preterm birth in pregnancies complicated by fetal gastroschisis, diagnosed by ultrasound scanning in time for preterm birth to be an option, and without other fetal anomalies. The intervention is planned preterm birth, prior to 37 weeks and 0 days' gestation, versus planned later birth, at or after 37 weeks and 0 days' gestation (mode of birth is not part of the intervention).We did not include quasi-randomised controlled trials and cluster trials. Cross-over trials are not appropriate for this condition. Studies that were presented in abstract form only were eligible for inclusion, providing that the population included women with pregnancies affected by fetal gastroschisis, the interventions were defined and the treatment selection was randomised. DATA COLLECTION AND ANALYSIS Two review authors independently assessed for inclusion the one trial identified as a result of the search strategy and assessed trial quality. Two review authors extracted data and checked it for accuracy. MAIN RESULTS We included one study, involving 40 infants and 42 women. The trial was underpowered to detect clinically important outcome differences between the two policies. There were no significant benefits or adverse effects of elective preterm birth at 36 weeks' gestation for fetal gastroschisis. The primary outcomes were caesarean section and neonatal survival to discharge. Two babies died after birth but before discharge in the elective (intervention) group versus none in the spontaneous group (risk ratio (RR) 5.00; 95% confidence interval (CI) 0.26 to 98.00; one study, n = 40). Seven women (33%) in the elective group and nine women (43%) in the spontaneous group delivered by caesarean section (RR 0.78; 95% CI 0.36 to 1.70).Similarly, for the secondary outcomes, there were no statistical differences in birthweight, ventilation requirements, necrotising enterocolitis and requirement for repeat surgery between the two groups. None of our prespecified maternal secondary outcomes were reported in the included study.We also examined gestational age at birth as a non-prespecified outcome. There was a difference in gestational age at birth between the two arms of the trial (35.8 weeks (SD 0.7) in the elective group and 36.7 (SD 1.5) in the spontaneous group. Possible reasons for this small mean difference include a trend towards spontaneous preterm birth in pregnancies complicated by fetal gastroschisis. AUTHORS' CONCLUSIONS This review is unable to draw any firm conclusions regarding preterm birth for infants with gastroschisis. It is not possible to say whether the intervention is beneficial or harmful for these babies or their mothers. Only one small trial is included. Further research is needed in this area.
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Affiliation(s)
- Natalie H Grant
- Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Abstract
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.
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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.
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Affiliation(s)
- Ann-Marie Kassa
- Department of Women's and Children's Health, Uppsala University, 751 05 Uppsala, Sweden
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Chen IL, Lee SY, Ou-Yang MC, Chao PH, Liu CA, Chen FS, Chung MY, Chen CC, Huang HC. Clinical presentation of children with gastroschisis and small for gestational age. Pediatr Neonatol 2011; 52:219-22. [PMID: 21835368 DOI: 10.1016/j.pedneo.2011.05.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 11/01/2010] [Accepted: 11/09/2010] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Gastroschisis (GS) is defined as a full-thickness paraumbilical abdominal wall defect associated with evisceration of fetal abdominal organ. Although the concomitant nongastrointestinal anomalies and aneuploidy are rarely presented, fetal growth restriction is common. The aim of this study is to compare the primary and secondary outcomes of GS between infants small for gestational age (SGA) and those appropriate for gestational age as well as term and late preterm infants. METHODS Chart records of neonates born with gestational age at or more than 34 weeks were reviewed. All babies received repair procedure immediately after birth. SGA was defined as birth weight for gestational age below the 10th percentile. The primary outcomes were the length of hospital stay, duration of total parental nutrition used, and the surgical complications. The secondary outcome was the percentile of body weight at 6 months old. RESULTS There were 21 babies diagnosed with GS from January 1990 to January 2010 at Kaohsiung Chang Gung Memorial Hospital. Four (19%) babies expired soon after operation. Nine (53%) of the 17 surviving babies had SGA. Length of hospital stay, surgical complications, and the percentile of body weight at 6 months old were significantly poorer for the SGA compared with appropriate for gestational age group (p = 0.005, 0.050, and 0.035). Furthermore, preterm neonates in SGA group had lower Apgar scores at 1 minute and 5 minutes than did term neonates (p = 0.045 and 0.031). CONCLUSION SGA commonly occurred in GS cases and it was associated with longer hospital stay, more operative complications, and less body weight gain. Our conclusion may provide informative data to parents of GS fetuses during prenatal consultation, and reminds us that long-term follow-up of these cases could be necessary.
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Affiliation(s)
- I-Lun Chen
- Department of Pediatrics, Division of Neonatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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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.
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Affiliation(s)
- Christopher W Snyder
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, USA
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Reigstad I, Reigstad H, Kiserud T, Berstad T. Preterm elective caesarean section and early enteral feeding in gastroschisis. Acta Paediatr 2011; 100:71-4. [PMID: 21143293 DOI: 10.1111/j.1651-2227.2010.01944.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS To evaluate the effect of elective caesarean section (CS) before term and early enteral nutrition on length of parenteral nutrition and hospital stay in infants with gastroschisis. METHODS Retrospective review of all infants with gastroschisis treated in a regional level III hospital from 1993 to 2008. During 1993-97, there was no established standard for management of pregnancy or delivery while a protocol on close foetal monitoring and early elective CS was adhered to for 1998-2008. Introduction of human milk on the first day after complete closure of the abdominal wall and rapid increase was the policy during the whole period. RESULTS With early elective CS, no foetal deaths occurred after 28-week gestational age (GA). Ten infants were born during the first period and 20 during the second period at a median GA (range) of 36.5 (34-40) and 35 (34-37) weeks (p = 0.013). Seven and 20, respectively, were born by CS. Median (range) days before full enteral feeds and hospital stay were 11.5 (7-39) and 13.0 (7-46) (p = 0.85), and 17.5 (12-36) and 22.5 (13-195) (p = 0.67), respectively. One child died of volvulus after discharge. CONCLUSION Close surveillance of pregnancy, elective preterm caesarean section, early surgery and active approach to primary closure and early enteral feeds appears to be a safe and effective line of management in gastroschisis.
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Affiliation(s)
- I Reigstad
- Department of Clinical Medicine, University of Bergen, Haukeland University Hospital, Norway
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Maramreddy H, Fisher J, Slim M, Lagamma EF, Parvez B. Delivery of gastroschisis patients before 37 weeks of gestation is associated with increased morbidities. J Pediatr Surg 2009; 44:1360-6. [PMID: 19573662 DOI: 10.1016/j.jpedsurg.2009.02.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Revised: 02/01/2009] [Accepted: 02/02/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite advances in the care of neonates with gastroschisis, patients present with significant morbidities. Preterm delivery of neonates with gastroschisis is often advocated to avoid the intestinal damage that may be sustained with prolonged exposure to amniotic fluid. However, preterm delivery may impose additional morbidities to this disease process. METHODS We conducted a retrospective review of patients with gastroschisis born from 1989 to 2007. Demographic and clinical data were collected. Preterm healthy neonates, with gestational age from 26 to 36 weeks, were used as controls. RESULTS Preterm infants with gastroschisis had a 14 times higher risk for any of the recorded morbidities. As compared to term neonates with gastroschisis, preterm neonates with gastroschisis had a higher rate of sepsis, longer duration to reach full enteral feedings, and longer length of stay. Although the preterm infants with gastroschisis were less likely to be small for gestational age at birth, they were as likely as the term infants with gastroschisis to have failure to thrive at discharge and had a greater drop in weight percentile during hospitalization. CONCLUSIONS Preterm delivery should be avoided because there is no clear benefit to the gut in avoiding derivative injuries. Meticulous attention should be given to the nutritional needs of patients with gastroschisis.
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Affiliation(s)
- Hima Maramreddy
- Department of Pediatrics, Division of Neonatology, Brenner Children's Hospital at Wake Forest University Baptist Medical Center, Winston-Salem, NC 27157, USA.
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White JJ. Gastroschisis: effect of mode of delivery. J Pediatr Surg 2009; 44:657-8; author reply 658-9. [PMID: 19302878 DOI: 10.1016/j.jpedsurg.2008.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Accepted: 11/05/2008] [Indexed: 11/28/2022]
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