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Slidell MB, McAteer J, Miniati D, Sømme S, Wakeman D, Rialon K, Lucas D, Beres A, Chang H, Englum B, Kawaguchi A, Gonzalez K, Speck E, Villalona G, Kulaylat A, Rentea R, Yousef Y, Darderian S, Acker S, St Peter S, Kelley-Quon L, Baird R, Baerg J. Management of Gastroschisis: Timing of Delivery, Antibiotic Usage, and Closure Considerations (A Systematic Review From the American Pediatric Surgical Association Outcomes & Evidence Based Practice Committee). J Pediatr Surg 2024; 59:1408-1417. [PMID: 38796391 DOI: 10.1016/j.jpedsurg.2024.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 03/08/2024] [Accepted: 03/17/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND No consensus exists for the initial management of infants with gastroschisis. METHODS The American Pediatric Surgical Association (APSA) Outcomes and Evidenced-based Practice Committee (OEBPC) developed three a priori questions about gastroschisis for a qualitative systematic review. We reviewed English-language publications between January 1, 1970, and December 31, 2019. This project describes the findings of a systematic review of the three questions regarding: 1) optimal delivery timing, 2) antibiotic use, and 3) closure considerations. RESULTS 1339 articles were screened for eligibility; 92 manuscripts were selected and reviewed. The included studies had a Level of Evidence that ranged from 2 to 4 and recommendation Grades B-D. Twenty-eight addressed optimal timing of delivery, 5 pertained to antibiotic use, and 59 discussed closure considerations (Figure 1). Delivery after 37 weeks post-conceptual age is considered optimal. Prophylactic antibiotics covering skin flora are adequate to reduce infection risk until definitive closure. Studies support primary fascial repair, without staged silo reduction, when abdominal domain and hemodynamics permit. A sutureless repair is safe, effective, and does not delay feeding or extend length of stay. Sedation and intubation are not routinely required for a sutureless closure. CONCLUSIONS Despite the large number of studies addressing the above-mentioned facets of gastroschisis management, the data quality is poor. A wide variation in gastroschisis management was documented, indicating a need for high quality RCTs to provide an evidence-based approach when caring for these infants. TYPE OF STUDY Qualitative systematic review of Level 1-4 studies.
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Affiliation(s)
- Mark B Slidell
- Division of Pediatric Surgery, Johns Hopkins Children's Center, 1800 Orleans St, Baltimore, MD 21287, USA.
| | - Jarod McAteer
- Providence Hospital, 101 West 8th Avenue, Spokane, WA 99204, USA
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Northern California, 1600 Eureka Road, Roseville, CA 95661, USA
| | - Stig Sømme
- Division of Pediatric Surgery, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Derek Wakeman
- University of Rochester Medical Center, School of Medicine and Dentistry, 601 Elmwood Ave, Box Surg, Rochester, NY 14642, USA
| | - Kristy Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street, Houston, TX 77030, USA
| | - Don Lucas
- Division of Pediatric Surgery, Department of General Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA
| | - Alana Beres
- Division of Pediatric Surgery, St. Christopher's Hospital for Children, 160 E Erie Ave, Philadelphia, PA 19134, USA
| | - Henry Chang
- Johns Hopkins All Children's Hospital, 501 6th Avenue South, St. Petersburg, FL 33701, USA
| | - Brian Englum
- University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201, USA
| | - Akemi Kawaguchi
- Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA
| | | | - Elizabeth Speck
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E Hospital Dr, Ann Arbor, MI 48109, USA
| | - Gustavo Villalona
- Division of Pediatric Surgery, Nemours Children's Health, 807 Children's Way, Jacksonville, FL 32207, USA
| | - Afif Kulaylat
- Division of Pediatric Surgery, Penn State Hershey Children's Hospital, 200 Campus Dr Ste 400, Hershey, PA 17033, USA
| | - Rebecca Rentea
- Pediatric Surgery Division, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, 1001 Decarie Boulevard, Montreal, Quebec, Canada H4A 3J1
| | - Sarkis Darderian
- Pediatric Surgery Division, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Shannon Acker
- Pediatric Surgery Division, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Shawn St Peter
- Pediatric Surgery Division, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Lorraine Kelley-Quon
- Pediatric Surgery Division, Children's Hospital, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Robert Baird
- Division of Pediatric General Surgery, Department of Surgery, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, 11th Floor, Vancouver, British Columbia V5Z 1M9, Canada
| | - Joanne Baerg
- Division of Pediatric Surgery, Presbyterian Health System, 201 Cedar St SE Ste 4660, Albuquerque, NM 87106, USA
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Anderson C, Li H, Cheboiwo V, Fisher S, Chepkemoi E, Rutto E, Carpenter K, Keung C, Saula P, Gray B. Uncomplicated gastroschisis care in the US and Kenya: Treatment at two tertiary care centers. J Pediatr Surg 2022; 57:1664-1670. [PMID: 34749982 DOI: 10.1016/j.jpedsurg.2021.09.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/08/2021] [Accepted: 09/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gastroschisis is a common birth defect with < 5% mortality in high income countries, but mortality in sub Saharan Africa remains high. We sought to compare gastroschisis management strategies and patient outcomes at tertiary pediatric referral centers in the United States and Kenya. METHODS This retrospective chart review examined uncomplicated gastroschisis patients treated at Riley Hospital for Children in Indianapolis, USA (n = 110), and Shoe4Africa Children's Hospital in Eldoret, Kenya (n = 75), from 2010 to 2018. Analyzed were completed using Chi square, Fisher's exact, and independent samples t tests and medians tests at the 95% significance level. RESULTS Survival in the American cohort was double that of the Kenyan cohort (99.1% vs 45.3%, p< 0.001). Sterile bag use for bowel containment was lower in Kenya (81.3% vs 98.1%, p< 0.001), but silo use was comparable at both institutions (p = 0.811). Kenyan patients had earlier median enteral feeding initiation (4vs 10 days, p< 0.001) and accelerated achievement of full enteral feeding (10vs 23 days, p< 0.001), but none received TPN. Despite earlier feeding, Kenyan patients displayed a higher prevalence of wound infections (70.8% vs 17.1%, p< 0.001) and sepsis (43.9% vs 4.8%, p< 0.001). In Kenya, survivors and non survivors displayed no difference in sterile bag use, hemodynamic stability, all cause infection rates, or antibiotic free hospital days. Defect closure (p< 0.001) and enteral feeding initiation (p< 0.001) were most predictive of survival. CONCLUSION Improving immediate response strategies for gastroschisis in Kenya could improve survival and decrease infection rates. Care strategies in the US can center on earlier enteral feeding initiation to reduce time to full feeding. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Cassandra Anderson
- Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN 46202, USA
| | - Helen Li
- Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN 46202, USA
| | - Vivian Cheboiwo
- Moi Teaching and Referral Hospital, P.O. Box 3-30100, Nandi Road, Uasin Gishu County, Eldoret, Kenya; Central and Southern Africa (COSECSA), College of Surgeons of East, 157 Olorien, Nijro Road ECSA HC, P.O. Box 1009, Arusha, Tanzania
| | - Sarah Fisher
- Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN 46202, USA
| | - Eunice Chepkemoi
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606 30100, Nandi Road, Uasin Gishu County, Eldoret, Kenya
| | - Emmy Rutto
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606 30100, Nandi Road, Uasin Gishu County, Eldoret, Kenya
| | - Kyle Carpenter
- Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN 46202, USA
| | - Connie Keung
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606 30100, Nandi Road, Uasin Gishu County, Eldoret, Kenya; Department of Surgery, Indiana University, School of Medicine, 545 Barnhill Dr., Emerson Hall, Indianapolis, IN 46202, USA
| | - Peter Saula
- Moi Teaching and Referral Hospital, P.O. Box 3-30100, Nandi Road, Uasin Gishu County, Eldoret, Kenya; Department of Surgery, Moi University, School of Medicine, P.O. Box 4606 30100, Nandi Road, Uasin Gishu County, Eldoret, Kenya
| | - Brian Gray
- Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN 46202, USA; Department of Surgery, Indiana University, School of Medicine, 545 Barnhill Dr., Emerson Hall, Indianapolis, IN 46202, USA.
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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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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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Gastroschisis: A State-of-the-Art Review. CHILDREN-BASEL 2020; 7:children7120302. [PMID: 33348575 PMCID: PMC7765881 DOI: 10.3390/children7120302] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/08/2020] [Accepted: 12/14/2020] [Indexed: 01/17/2023]
Abstract
Gastroschisis, the most common type of abdominal wall defect, has seen a steady increase in its prevalence over the past several decades. It is identified, both prenatally and postnatally, by the location of the defect, most often to the right of a normally-inserted umbilical cord. It disproportionately affects young mothers, and appears to be associated with environmental factors. However, the contribution of genetic factors to the overall risk remains unknown. While approximately 10% of infants with gastroschisis have intestinal atresia, extraintestinal anomalies are rare. Prenatal ultrasound scans are useful for early diagnosis and identification of features that predict a high likelihood of associated bowel atresia. The timing and mode of delivery for mothers with fetuses with gastroschisis have been somewhat controversial, but there is no convincing evidence to support routine preterm delivery or elective cesarean section in the absence of obstetric indications. Postnatal surgical management is dictated by the condition of the bowel and the abdominal domain. The surgical options include either primary reduction and closure or staged reduction with placement of a silo followed by delayed closure. The overall prognosis for infants with gastroschisis, in terms of both survival as well as long-term outcomes, is excellent. However, the management and outcomes of a subset of infants with complex gastroschisis, especially those who develop short bowel syndrome (SBS), remains challenging. Future research should be directed towards identification of epidemiological factors contributing to its rising incidence, improvement in the management of SBS, and obstetric/fetal interventions to minimize intestinal damage.
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Shamshirsaz AA, Lee TC, Hair AB, Erfani H, Espinoza J, Shamshirsaz AA, Fox KA, Gandhi M, Nassr AA, Abrams SA, Mccullough LB, Chervenak FA, Olutoye OO, Belfort MA. Elective delivery at 34 weeks vs routine obstetric care in fetal gastroschisis: randomized controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:15-19. [PMID: 31503365 DOI: 10.1002/uog.21871] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To evaluate whether elective preterm delivery (ED) at 34 weeks is of postnatal benefit to infants with isolated gastroschisis compared with routine obstetric care (RC). METHODS Between May 2013 and September 2015, all women with a sonographic diagnosis of fetal gastroschisis referred to a single tertiary center, before 34 weeks' gestation, were invited to participate in this study. Eligible patients were randomized to ED (induction of labor at 34 weeks) or RC (spontaneous labor or delivery by 37-38 weeks, based on standard obstetric indications). The primary outcome measure was length of time on total parenteral nutrition (TPN). Secondary outcomes were time to closure of gastroschisis and length of stay in hospital. Outcome variables were compared using appropriate statistical methods. Analysis was based on intention-to-treat. RESULTS Twenty-five women were assessed for eligibility, of whom 21 (84%; 95% CI, 63.9-95.5%) agreed to participate in the study; of these, 10 were randomized to ED and 11 to RC. The trial was stopped at the first planned interim analysis due to patient safety concerns and for futility; thus, only 21 of the expected 86 patients (24.4%; 95% CI, 15.8-34.9%) were enrolled. Median gestational age at delivery was 34.3 (range, 34-36) weeks in the ED group and 36.7 (range, 27-38) weeks in the RC group. One patient in the ED group delivered at 36 weeks following unsuccessful induction at 34 weeks. Neonates of women who underwent ED, compared to those in the RC group, showed no difference in the median number of days on TPN (54 (range, 17-248) vs 21 (range, 9-465) days; P = 0.08), number of days to closure of gastroschisis (7 (range, 0-15) vs 5 (range, 0-8) days; P = 0.28) and length of stay in hospital (70.5 (range, 22-137) vs 31 (range, 19-186) days; P = 0.15). However, neonates in the ED group were significantly more likely to experience late-onset sepsis compared with those in the RC group (40% (95% CI, 12.2-73.8%) vs 0%; P = 0.03). CONCLUSION This study demonstrates no benefit of ED of fetuses with gastroschisis when postnatal gastroschisis management is similar to that used in routine care. Rather, the data suggest that ED is detrimental to infants with gastroschisis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A A Shamshirsaz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - T C Lee
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - A B Hair
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - H Erfani
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - J Espinoza
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - A A Shamshirsaz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - K A Fox
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - M Gandhi
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - A A Nassr
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - S A Abrams
- University of Texas at Austin, Austin, TX, USA
| | - L B Mccullough
- Department of Obstetrics and Gynecology, Weill Medical College of Cornell University/New York Presbyterian Hospital, New York, NY, USA
| | - F A Chervenak
- Department of Obstetrics and Gynecology, Weill Medical College of Cornell University/New York Presbyterian Hospital, New York, NY, USA
| | - O O Olutoye
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - M A Belfort
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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Stallings EB, Isenburg JL, Short TD, Heinke D, Kirby RS, Romitti PA, Canfield MA, O'Leary LA, Liberman RF, Forestieri NE, Nembhard WN, Sandidge T, Nestoridi E, Salemi JL, Nance AE, Duckett K, Ramirez GM, Shan X, Shi J, Lupo PJ. Population-based birth defects data in the United States, 2012-2016: A focus on abdominal wall defects. Birth Defects Res 2019; 111:1436-1447. [PMID: 31642616 DOI: 10.1002/bdr2.1607] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND/OBJECTIVES In this report, the National Birth Defects Prevention Network (NBDPN) examines and compares gastroschisis and omphalocele for a recent 5-year birth cohort using data from 30 population-based birth defect surveillance programs in the United States. METHODS As a special call for data for the 2019 NBDPN Annual Report, state programs reported expanded data on gastroschisis and omphalocele for birth years 2012-2016. We estimated the overall prevalence (per 10,000 live births) and 95% confidence intervals (CI) for each defect as well as by maternal race/ethnicity, maternal age, infant sex, and case ascertainment methodology utilized by the program (active vs. passive). We also compared distribution of cases by maternal and infant factors and presence/absence of other birth defects. RESULTS The overall prevalence estimates (per 10,000 live births) were 4.3 (95% CI: 4.1-4.4) for gastroschisis and 2.1 (95% CI: 2.0-2.2) for omphalocele. Gastroschisis was more frequent among young mothers (<25 years) and omphalocele more common among older mothers (>40 years). Mothers of infants with gastroschisis were more likely to be underweight/normal weight prior to pregnancy and mothers of infants with omphalocele more likely to be overweight/obese. Omphalocele was twice as likely as gastroschisis to co-occur with other birth defects. CONCLUSIONS This report highlights important differences between gastroschisis and omphalocele. These differences indicate the importance of distinguishing between these defects in epidemiologic assessments. The report also provides additional data on co-occurrence of gastroschisis and omphalocele with other birth defects. This information can provide a basis for future research to better understand these defects.
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Affiliation(s)
- Erin B Stallings
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, Georgia.,Carter Consulting, Incorporated, Atlanta, Georgia
| | - Jennifer L Isenburg
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, Georgia
| | - Tyiesha D Short
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, Georgia.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Dominique Heinke
- Massachusetts Department of Public Health, Center for Birth Defects Research and Prevention, Boston, Massachusetts
| | - Russell S Kirby
- College of Public Health, University of South Florida, Tampa, Florida
| | - Paul A Romitti
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Mark A Canfield
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas
| | - Leslie A O'Leary
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, Georgia
| | - Rebecca F Liberman
- Massachusetts Department of Public Health, Center for Birth Defects Research and Prevention, Boston, Massachusetts
| | - Nina E Forestieri
- Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina
| | - Wendy N Nembhard
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Arkansas Center for Birth Defects Research and Prevention, Little Rock, Arkansas
| | | | - Eirini Nestoridi
- Massachusetts Department of Public Health, Center for Birth Defects Research and Prevention, Boston, Massachusetts
| | - Jason L Salemi
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
| | - Amy E Nance
- Utah Birth Defect Network, Division of Family Health and Preparedness, Utah Department of Health, Salt Lake City, Utah
| | | | - Glenda M Ramirez
- Arizona Birth Defects Monitoring Program, Arizona Department of Health Services, Phoenix, Arizona
| | - Xiaoyi Shan
- Arkansas Reproductive Health Monitoring System, Arkansas Children's Research Institute, Little Rock, Arkansas
| | - Jing Shi
- Special Child Health and Early Intervention Services, New Jersey Department of Health, Trenton, New Jersey
| | - Philip J Lupo
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas
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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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10
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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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11
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Pearl RH, Esparaz JR, Nierstedt RT, Elger BM, DiSomma NM, Leonardi MR, Macwan KS, Jeziorczak PM, Munaco AJ, Vegunta RK, Aprahamian CJ. Single center protocol driven care in 150 patients with gastroschisis 1998-2017: collaboration improves results. Pediatr Surg Int 2018; 34:1171-1176. [PMID: 30255354 DOI: 10.1007/s00383-018-4349-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2018] [Indexed: 01/05/2023]
Abstract
PURPOSE The treatment of gastroschisis (GS) using our collaborative clinical pathway, with immediate attempted abdominal closure and bowel irrigation with a mucolytic agent, was reviewed. METHODS A retrospective review of the past 20 years of our clinical pathway was performed on neonates with GS repair at our institution. The clinical treatment includes attempted complete reduction of GS defect within 2 h of birth. In the operating room, the bowel is evaluated and irrigated with mucolytic agent to evacuate the meconium and decompress the bowel. No incision is made and a neo-umbilicus is created. Clinical outcomes following closure were assessed. RESULTS 150 babies with gastroschisis were reviewed: 109 (77%) with a primary repair, 33 (23%) with a spring-loaded silo repair. 8 babies had a delayed closure and were not included in the statistical analysis. Successful primary repair and time to closure had a significant relationship with all outcome variables-time to extubation, days to initiate feeds, days to full feeds, and length of stay. CONCLUSION Early definitive closure of the abdominal defect with mucolytic bowel irrigation shortens time to first feeds, total TPN use, time to extubation, and length of stay.
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Affiliation(s)
- Richard H Pearl
- Department of Surgery, University of Illinois College of Medicine, Peoria, IL, USA. .,Children's Hospital of Illinois, OSF Saint Francis Medical Center, 420 NE Glen Oak Avenue, Suite 101-01, Peoria, IL, 61603, USA.
| | - Joseph R Esparaz
- Department of Surgery, University of Illinois College of Medicine, Peoria, IL, USA
| | - Ryan T Nierstedt
- Children's Hospital of Illinois, OSF Saint Francis Medical Center, 420 NE Glen Oak Avenue, Suite 101-01, Peoria, IL, 61603, USA
| | - Breanna M Elger
- Children's Hospital of Illinois, OSF Saint Francis Medical Center, 420 NE Glen Oak Avenue, Suite 101-01, Peoria, IL, 61603, USA
| | | | - Michael R Leonardi
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Illinois College of Medicine, Peoria, IL, USA
| | - Kamlesh S Macwan
- Children's Hospital of Illinois, OSF Saint Francis Medical Center, 420 NE Glen Oak Avenue, Suite 101-01, Peoria, IL, 61603, USA.,Division of Neonatal Medicine, Children's Hospital of Illinois, Peoria, IL, USA
| | - Paul M Jeziorczak
- Department of Surgery, University of Illinois College of Medicine, Peoria, IL, USA.,Children's Hospital of Illinois, OSF Saint Francis Medical Center, 420 NE Glen Oak Avenue, Suite 101-01, Peoria, IL, 61603, USA
| | - Anthony J Munaco
- Department of Surgery, University of Illinois College of Medicine, Peoria, IL, USA.,Children's Hospital of Illinois, OSF Saint Francis Medical Center, 420 NE Glen Oak Avenue, Suite 101-01, Peoria, IL, 61603, USA
| | - Ravindra K Vegunta
- Department of Pediatric Surgery, Banner Desert Medical Center, Mesa, AZ, USA
| | - Charles J Aprahamian
- Department of Surgery, University of Illinois College of Medicine, Peoria, IL, USA.,Children's Hospital of Illinois, OSF Saint Francis Medical Center, 420 NE Glen Oak Avenue, Suite 101-01, Peoria, IL, 61603, USA
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12
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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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13
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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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14
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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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15
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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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16
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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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17
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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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18
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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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19
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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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20
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Perinatal outcomes and hospital costs in gastroschisis based on gestational age at delivery. Obstet Gynecol 2015; 124:543-550. [PMID: 25162254 DOI: 10.1097/aog.0000000000000427] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the association between gestational age at delivery and perinatal outcomes among gastroschisis-affected pregnancies that result in live birth. METHODS We conducted a retrospective cohort study using a linked maternal-infant database for more than 2.3 million liveborn neonates in Florida from 1998 to 2009. Cases were identified using a combination of International Classification of Diseases, 9th Edition, Clinical Modification, diagnosis and procedure codes indicative of gastroschisis. We restricted our analyses to singleton cases without another major birth defect or medical conditions that would justify early elective delivery. We categorized cases based on gestational age in weeks and compared perinatal outcomes. RESULTS Among 1,005 neonates with gastroschisis, 324 (32.3%) were isolated, singleton cases without an additional indication for early delivery. We observed decreased rates of adverse pregnancy outcomes among those neonates delivered in the early term period (37-38 weeks of gestation) compared with preterm (less than 34 weeks of gestation); specifically, jaundice (18.5% compared with 42.3%, P=.01) and respiratory distress syndrome (5.9% compared with 23.1%, P≤.01). As the gestational age at birth increased, we observed fewer mean number of days spent in the hospital (less than 34 weeks of gestation: 55.9, P<.01; 34-36 weeks of gestation: 51.9, P=.02; 37-38 weeks of gestation: 36.9 [reference]) and lower direct inpatient medical costs (in thousands, U.S. dollars; less than 34 weeks of gestation: 79, P=.01; 34-36 weeks of gestation: 71, P=.04; 37-38 weeks of gestation: 51 [reference]) per infant in the first year of life. CONCLUSION In pregnancies complicated by gastroschisis, and with no other known major indications, birth at early term or later term gestation, when compared with delivery before 37 weeks of gestation, is associated with improved perinatal outcomes and lower medical costs. LEVEL OF EVIDENCE II.
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21
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Savoie KB, Huang EY, Aziz SK, Blakely ML, Dassinger S, Dorale AR, Duggan EM, Harting MT, Markel TA, Moore-Olufemi SD, Shah SR, St Peter SD, Tsao K, Wyrick DL, Williams RF. Improving gastroschisis outcomes: does birth place matter? J Pediatr Surg 2014; 49:1771-5. [PMID: 25487481 DOI: 10.1016/j.jpedsurg.2014.09.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 09/05/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Babies born in the hospital where they obtain definitive surgical care do not require transportation between institutions and may have shorter time to surgical intervention. Whether these differences result in meaningful improvement in outcomes has been debated. A multi-institutional retrospective study was performed comparing outcomes based on birthplace. METHODS Six institutions within the PedSRC reviewed infants born with gastroschisis from 2008 to 2013. Birthplace, perinatal, and postoperative data were collected. Based on the P-NSQIP definition, inborn was defined as birth at the pediatric hospital where repair occurred. The primary outcome was days to full enteral nutrition (FEN; 120kcal/kg/day). RESULTS 528 patients with gastroschisis were identified: 286 inborn, 242 outborn. Days to FEN, time to bowel coverage and abdominal wall closure, primary closure rate, and length of stay significantly favored inborn patients. In multivariable analysis, birthplace was not a significant predictor of time to FEN. Gestational age, presence of atresia or necrosis, primary closure rate, and time to abdominal wall closure were significant predictors. CONCLUSIONS Inborn patients had bowel coverage and definitive closure sooner with fewer days to full feeds and shorter length of stay. Birthplace appears to be important and should be considered in efforts to improve outcomes in patients with gastroschisis.
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Affiliation(s)
- Kate B Savoie
- University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Eunice Y Huang
- University of Tennessee Health Science Center, Memphis, Tennessee.
| | | | | | | | - Amanda R Dorale
- Indiana University School of Medicine, Indianapolis, Indiana.
| | | | | | - Troy A Markel
- Indiana University School of Medicine, Indianapolis, Indiana.
| | | | - Sohail R Shah
- University of Missouri-Kansas City, Kansas City, Missouri.
| | | | - Koujen Tsao
- University of Texas at Houston, Houston, Texas.
| | | | - Regan F Williams
- University of Tennessee Health Science Center, Memphis, Tennessee.
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Yang EY, Davies LM, Buchanan P, Kling C, Banyard DA, Ramones T. Spontaneous onset of labor, not route of delivery, is associated with prolonged length of stay in babies with gastroschisis. J Pediatr Surg 2014; 49:1776-81. [PMID: 25487482 DOI: 10.1016/j.jpedsurg.2014.09.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 09/05/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND/PURPOSE We studied obstetric delivery practices for fetal gastroschisis and correlated this with neonatal outcomes. Our objectives were to identify changes in delivery practices over time and to determine if these changes resulted in improved neonatal outcomes. METHODS After IRB approval, maternal and neonatal records from 219 gastroschisis births between 1990 and 2008 were reviewed. Obstetrical data and neonatal data were collected. Univariate comparisons were made between maternal delivery variables and neonatal outcomes. Significant and clinically relevant obstetrical variables were combined for multivariate linear regression modeling. RESULTS The practice of elective cesarean delivery (ELCS) shifted to spontaneous vaginal delivery (sVD) over time (p <0.001). Babies born by sVD had longer hospitalization than those born by ELCS (median 36.0 vs 21.6days, p <0.05). Gestational age (GA) and birth weight were similar between groups. Babies born by induced VD (iVD) had short hospitalization (median 22.5days). A linear regression model demonstrated that spontaneous onset of labor (SOL) and GA were independently related to LOS. CONCLUSIONS Over nearly two decades, delivery of gastroschisis babies shifted from ELCS to sVD, a practice associated with a significantly longer LOS. Regression models suggest that shorter LOS could be achieved if elective delivery modes are utilized prior to SOL.
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Affiliation(s)
- Edmund Y Yang
- Department of Pediatric Surgery, Children's Hospital of Illinois, Peoria, Illinois, 61603.
| | - Lauren M Davies
- Saint Louis University School of Medicine, Saint Louis, Missouri, 63104
| | - Paula Buchanan
- Saint Louis University Center for Outcomes Research, Saint Louis, Missouri, 63104
| | - Catherine Kling
- Department of Surgery, Vanderbilt University School of Medicine, 37212
| | - Derek A Banyard
- Center for Tissue Engineering, University of California, Irvine, Irvine, California, 92868
| | - Theresa Ramones
- Department of Surgery, Oregon Health and Sciences University, Portland, Oregon, 97239
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23
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Friedmacher F, Hock A, Castellani C, Avian A, Höllwarth ME. Gastroschisis-related complications requiring further surgical interventions. Pediatr Surg Int 2014; 30:615-20. [PMID: 24736970 DOI: 10.1007/s00383-014-3500-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of this study was to determine the incidence of gastroschisis-related complications (GRCs) after closure of the abdominal wall defect, with a focus on frequency, type and timing of required surgical interventions, and to identify the impact of these on further outcome. METHODS All gastroschisis patients treated from 1975 to 2008 in a tertiary-level center were retrospectively reviewed. Surgical procedures for GRCs following abdominal wall closure of simple gastroschisis [SG (intact continuous bowel)] and complex gastroschisis [CG (additional gastrointestinal malformations)] were compared, and outcomes were determined. RESULTS One hundred and eight patients were identified with a median follow-up of 15.0 years (range 4-37). Ninety-four (87%) had SG, and 14 (13%) CG. Surgical interventions for GRCs were performed in 28 (26%) patients with 16 requiring multiple operations. Overall, 60 surgical procedures were performed. Bowel obstruction (n = 34) was the most common GRC, followed by anastomotic stricture (n = 8) and ischemic bowel (n = 3). The median interval between gastroschisis closure and secondary surgery for GRCs was 62.5 days (range 1 day-15 years). Surgical interventions were significantly more frequent in CG compared with SG [12/14 (86%) vs. 16/94 (17%); P < 0.0001]. The overall survival rate was 90%. Significantly, more patients required parenteral nutrition for more than 28 days [9/28 (32%) vs. 13/80 (16 %); P = 0.0468], longer median time to achieve full enteral feedings (87 vs. 33 days; P < 0.0001) and longer median hospital stay (117 vs. 54 days; P < 0.0001) compared with those not requiring additional surgery. CONCLUSION GRCs requiring surgical interventions were more common in patients with CG, which were associated with delay in achieving full enteral feedings and prolonged hospital stay.
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Affiliation(s)
- Florian Friedmacher
- Department of Pediatric and Adolescent Surgery, Medical University Graz, Auenbruggerplatz 34, 8036, Graz, Austria,
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24
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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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25
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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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26
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South AP, Stutey KM, Meinzen-Derr J. Metaanalysis of the prevalence of intrauterine fetal death in gastroschisis. Am J Obstet Gynecol 2013; 209:114.e1-13. [PMID: 23628262 DOI: 10.1016/j.ajog.2013.04.032] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 04/02/2013] [Accepted: 04/24/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of this study was to review the medical literature that has reported the risk for intrauterine fetal death (IUFD) in pregnancies with gastroschisis. STUDY DESIGN We systematically searched the literature to identify all published studies of IUFD and gastroschisis through June 2011 that were archived in MEDLINE, PubMed, or referenced in published manuscripts. The MESH terms gastroschisis or abdominal wall defect were used. RESULTS Fifty-four articles were included in the metaanalysis. There were 3276 pregnancies in the study and a pooled prevalence of IUFD of 4.48 per 100. Those articles that included gestational age of IUFD had a pooled prevalence of IUFD of 1.28 per 100 births at ≥36 weeks' gestation. The prevalence did not appear to increase at >35 weeks' gestation. CONCLUSION The overall incidence of IUFD in gastroschisis is much lower than previously reported. The largest risk of IUFD occurs before routine and elective early delivery would be acceptable. Risk for IUFD should not be the primary indication for routine elective preterm delivery in pregnancies that are affected by gastroschisis.
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Affiliation(s)
- Andrew P South
- Division of Neonatology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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27
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van Manen M, Hendson L, Wiley M, Evans M, Taghaddos S, Dinu I. Early childhood outcomes of infants born with gastroschisis. J Pediatr Surg 2013; 48:1682-7. [PMID: 23932607 DOI: 10.1016/j.jpedsurg.2013.01.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 12/17/2012] [Accepted: 01/07/2013] [Indexed: 12/12/2022]
Abstract
PURPOSE To describe neonatal and childhood outcomes of a contemporary cohort of infants with gastroschisis. METHODS Observational, single center, inception cohort of children born with gastroschisis from January 2005 to December 2008. RESULTS Of 63 infants, 61 survived to hospital discharge and 39 were seen for follow-up. Complications included sepsis (37%), necrotizing enterocolitis (10%), parenteral nutrition related cholestasis (25%), and short bowel syndrome (13%). Of survivors, 5% had visual impairment and 10% had hearing loss. No child tested had mental delay or cerebral palsy. Early gestational age predicted death or disability (OR 0.60, 95% CI 0.38, 0.96; p=0.033). There was a high incidence of prescription medications for presumed gastroesophageal reflux (90%). Some infants continued to require tube feeds (15%). There were improvements in longitudinal growth reflected in increasing z-scores. CONCLUSIONS Although children with gastroschisis are at risk for disability, childhood outcomes are encouraging.
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Affiliation(s)
- Michael van Manen
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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28
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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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29
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Emil S, Canvasser N, Chen T, Friedrich E, Su W. Contemporary 2-year outcomes of complex gastroschisis. J Pediatr Surg 2012; 47:1521-8. [PMID: 22901911 DOI: 10.1016/j.jpedsurg.2011.12.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 12/20/2011] [Accepted: 12/21/2011] [Indexed: 11/18/2022]
Abstract
PURPOSE Outcomes of gastroschisis are influenced by associated intestinal complications. We present a detailed analysis of complex gastroschisis. METHODS A retrospective study of all patients with gastroschisis treated at 2 university neonatal intensive care units between January 1, 2001, and March 31, 2007, was performed. RESULTS Of 83 patients, 19 (23%) had complex gastroschisis, including atresias (68%), gangrene (37%), closing gastroschisis (32%), perforation (21%), strictures (21%), and volvulus (11%). Prenatal ultrasound did not predict complications. Fifty-three percent underwent primary closure. Duration of mechanical ventilation and total parenteral nutrition (TPN) was 14.4 ± 1.9 days and 90.7 ± 9.0 days, respectively. Enteral feeds started at 35.9 ± 4.6 days. Hospital stay was 104.4 ± 9.6 days. Patients underwent a median of 3 abdominal procedures (range, 2-5) before discharge. Ninety-five percent survived to discharge; 33% and 67% were discharged on TPN and gastrostomy feeds, respectively. Two-year survival was 89%, with 82% on full oral feeding, 12% on a combination of oral and gastrostomy feeding, and 1 patient (who received a liver/bowel transplant) on a combination of enteral and parenteral nutrition. CONCLUSIONS Complex gastroschisis continues to produce significant morbidity. However, most of the patients are TPN free by 2 years of age.
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Affiliation(s)
- Sherif Emil
- Division of Pediatric Surgery, University of California Irvine School of Medicine, Orange, California, USA.
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30
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Bucher BT, Mazotas IG, Warner BW, Saito JM. Effect of time to surgical evaluation on the outcomes of infants with gastroschisis. J Pediatr Surg 2012; 47:1105-10. [PMID: 22703778 PMCID: PMC3658821 DOI: 10.1016/j.jpedsurg.2012.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 03/05/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Our goal is to identify the impact of time to surgical intervention on the outcomes of infants with gastroschisis. METHODS After institutional review board approval, we performed a retrospective review of the medical records of all infants admitted to our institution from 2001 to 2010. Transport, bowel stabilization, and closure times were defined as the time from birth to admission, admission to the first-documented operative intervention, and first operative intervention to abdominal closure, respectively. Outcomes included age at full enteral feeds, total parental nutrition days, ventilator days, and hospital length of stay. Multivariate analysis was used to identify independent predictors of the outcomes. RESULTS One hundred eighteen infants with gastroschisis were included in our study. Transport and bowel stabilization times were not predictive of any outcome. However, the time to abdominal wall closure and postnatal gastrointestinal complications were independently predictive of age at full enteral feeds, total parenteral nutrition days, and hospital length of stay. CONCLUSION Time to surgical evaluation/bowel stabilization was not predictive of any clinically relevant outcomes in infants with gastroschisis. These data demonstrate that potential benefits from prenatal regionalization of infants with gastroschisis are not supported by decreased time to operative intervention.
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31
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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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32
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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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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.
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Affiliation(s)
- Anna-May Long
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, United Kingdom
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Johnson S, Kimball S. Gastroschisis and extreme prematurity: a report of two survivors. J Pediatr Surg 2011; 46:1274-6. [PMID: 21683237 DOI: 10.1016/j.jpedsurg.2011.02.057] [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] [Received: 11/15/2010] [Revised: 01/29/2011] [Accepted: 02/17/2011] [Indexed: 10/18/2022]
Abstract
Extreme prematurity is not commonly associated with gastroschisis, and there are no reports of babies surviving with both gastroschisis and extreme prematurity. We report 2 such cases.
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Affiliation(s)
- Sidney Johnson
- Hawai'i Pacific Health and Kapiolani Medical Center for Women and Children, Mililani, HI 96789, USA
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Baird R, Eeson G, Safavi A, Puligandla P, Laberge JM, Skarsgard ED. Institutional practice and outcome variation in the management of congenital diaphragmatic hernia and gastroschisis in Canada: a report from the Canadian Pediatric Surgery Network. J Pediatr Surg 2011; 46:801-7. [PMID: 21616230 DOI: 10.1016/j.jpedsurg.2011.02.008] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 02/11/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perinatal management of congenital diaphragmatic hernia (CDH) and gastroschisis (GS) remains nonstandardized and institution specific. This analysis describes practice and outcome variation across a national network. METHODS A national, prospective, disease-specific database for CDH and GS was evaluated over 4 years. Centers were evaluated individually and defined as low (low-volume center [LVC]) or high (high-volume center [HVC]) volume based on case mean. RESULTS Congenital diaphragmatic hernia. Two hundred fifteen liveborn cases were studied (mean, 14.3 cases/center) across 15 centers (8 LVCs and 7 HVCs). Significant interinstitutional practice variation was noted in rates of termination (0%-40%) and cesarean delivery (0%-61%). Centers demonstrated marked variation in ventilation strategies, vasodilator and paralytic use, timing of surgery, and rates of primary closure. Overall survival was 81.4% (LVC, 76.9%; HVC, 82.4%; P = .43). Gastroschisis. Four hundred sixteen cases were investigated (mean, 26 cases/center; range, 6-72) across 16 centers (10 LVCs and 6 HVCs). Cesarean delivery rates varied widely between centers (0%-86%) as did timing of closure (early vs delayed, 1%-100%). There was no difference in length of stay, days on total parenteral nutrition, and overall survival (94.3% vs 97.2%; P = .17) between LVCs and HVCs. CONCLUSIONS The existence of perinatal practice and outcome variation for GS and CDH suggests targets for improved delivery of care and justifies efforts to standardize treatment on a national basis.
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Affiliation(s)
- Robert Baird
- Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada.
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36
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Mortellaro VE, St Peter SD, Fike FB, Islam S. Review of the evidence on the closure of abdominal wall defects. Pediatr Surg Int 2011; 27:391-7. [PMID: 21161242 DOI: 10.1007/s00383-010-2803-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2010] [Indexed: 10/18/2022]
Abstract
Infants with congenital abdominal wall defects pose an interesting and challenging management issue for surgeons. We attempt to review the literature to define the current treatment modalities and their application in practice. In gastroschisis, the overall strategies for repair include immediate closure or delayed operative repair. The best level of data for gastroschisis is grade C and appears to support that there is no major difference in survival between immediate closure or delayed repair. In patients with omphalocele, the management techniques are more varied consisting of immediate closure, staged closure or delayed closure after epithelialization. The literature is less clear on when to use one technique over the other, consisting of mostly grade D and E data. In patients with omphalocele, a registry to collect information on patients with larger defects may help determine which of the management strategies is optimal.
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Affiliation(s)
- Vincent E Mortellaro
- Department of Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
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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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Grapin-Dagorno C, Noche ME, Boubnova J. [Surgical treatment of omphalocele and gastroschisis: prognostic factors]. Arch Pediatr 2010; 17:820-1. [PMID: 20654910 DOI: 10.1016/s0929-693x(10)70128-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Soares H, Silva A, Rocha G, Pissarra S, Correia-Pinto J, Guimarães H. Gastroschisis: preterm or term delivery? Clinics (Sao Paulo) 2010; 65:139-42. [PMID: 20186296 PMCID: PMC2827699 DOI: 10.1590/s1807-59322010000200004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Accepted: 11/03/2009] [Indexed: 11/22/2022] Open
Abstract
AIM The main objective of this study was to evaluate the association between prematurity and the time to achieve full enteral feeding in newborns with gastroschisis. The second objective was to analyze the associations between length of hospital stay and time to achieve full enteral feeding with mode of delivery, birth weight and surgical procedure. METHODS The medical records of newborns with gastroschisis treated between 1997 and 2007 were reviewed. Two groups were considered: those delivered before 37 weeks (group A) and those delivered after 37 weeks (group B). The variables of gestational age, mode of delivery, birth weight, time to achieve full enteral feeding, length of hospital stay and surgical approach were analyzed and compared between groups. RESULTS Forty-one patients were studied. In Group A, there were 14 patients with a mean birth weight (BW) of 2300 g (range=1680-3000) and a mean gestational age (GA) of 36 weeks (range=34-36). In group B, there were 24 patients with a mean BW of 2700 g (range=1500-3550) and a mean GA of 38 weeks (range=37-39). The mean time to achieve full enteral feeding was 30.1+/-6.7 days in group A and 17.0+/-2.5 days in group B (p=0.09) with an OR of 0.82 and a 95% CI of 0.20-3.23 after adjustment for sepsis and BW. No statistical difference was found between low BW (<2500 g), mode of delivery and number of days to achieve full enteral feeding (p=0.34 and p=0.13, respectively). Patients with BW over 2500 g had fewer days in the hospital (22.9+/-3.1 vs. 35.7+/-5.7 days; p=0.06). CONCLUSION The results of this study do not support the idea of anticipating the delivery of fetuses with gastroschisis in order to achieve full enteral feeding earlier.
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Affiliation(s)
- Henrique Soares
- Neonatology Department, São João Hospital and Porto Medical School – Porto/Portugal
| | - Ana Silva
- Pediatrics Surgery Department, São João Hospital – Porto/Portugal,
, Tel.: 35 1 916108761
| | - Gustavo Rocha
- Neonatology Department, São João Hospital and Porto Medical School – Porto/Portugal
| | - Susana Pissarra
- Neonatology Department, São João Hospital and Porto Medical School – Porto/Portugal
| | - Jorge Correia-Pinto
- Pediatrics Surgery Department, São João Hospital – Porto/Portugal,
, Tel.: 35 1 916108761
| | - Hercília Guimarães
- Neonatology Department, São João Hospital and Porto Medical School – Porto/Portugal
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