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Jaczyńska R, Mikulska B, Nimer A, Mydlak D, Sawicka E, Maciejewski T. Prenatal ultrasound markers for prediction of complex gastroschisis-single-center retrospective cohort study. J Perinatol 2024; 44:1325-1334. [PMID: 38898181 DOI: 10.1038/s41372-024-02009-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/22/2024] [Accepted: 05/14/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE To evaluate prenatal ultrasound markers for distinguishing simple gastroschisis (sGS) from complex gastroschisis (cGS) and identifying fetuses at risk of complications. STUDY DESIGN A retrospective cohort study analyzed 61 fetuses with isolated gastroschisis at a tertiary center from 2011 to 2021, utilizing serial ultrasounds from 14 to 35 weeks' gestation. A general linear model, quantile regression, and logistic regression assessed ultrasound markers, fetal weeks, and gastroschisis risk, yielding predictive models. RESULTS IABL dilatation showed the highest PPV but low NPV. Non-free floating bowel loops (NFFBL) indicated the best PPV to NPV ratio. Combinations of markers yielded the highest predictive value for cGS. EABL collapsed and non-free floating bowel loops were significant, consistent risk factors. CONCLUSIONS Prenatal ultrasounds can predict cGS risk, particularly using IABL dilatation and NFFBL as markers. Accurate assessment requires considering gestational age, qualitative symptoms, emphasizing experienced perinatologists' role and monitoring, particularly after 30 weeks of gestation.
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Affiliation(s)
- Renata Jaczyńska
- Department of Obstetrics and Gyneacology, Institute of Mother and Child, Warsaw, Poland.
| | - Boyana Mikulska
- Department of Obstetrics and Gyneacology, Institute of Mother and Child, Warsaw, Poland
| | - Anna Nimer
- Department of Obstetrics and Gyneacology, Institute of Mother and Child, Warsaw, Poland
| | - Dariusz Mydlak
- Department of Pediatric and Adolescent Surgery, Institute of Mother and Child, Warsaw, Poland
| | - Ewa Sawicka
- Department of Pediatric and Adolescent Surgery, Institute of Mother and Child, Warsaw, Poland
| | - Tomasz Maciejewski
- Department of Obstetrics and Gyneacology, Institute of Mother and Child, Warsaw, Poland
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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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Sun RC, Hessami K, Krispin E, Pammi M, Mostafaei S, Joyeux L, Deprest J, Keswani S, Lee TC, King A, Belfort MA, Shamshirsaz AA. Prenatal ultrasonographic markers for prediction of complex gastroschisis and adverse perinatal outcomes: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022; 107:371-379. [PMID: 34607856 DOI: 10.1136/archdischild-2021-322612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/17/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE We sought to perform a meta-analysis of the predictive value of antenatal ultrasonographic markers of bowel dilation, gastric dilation, polyhydramnios and abdominal circumference that predict complex gastroschisis and adverse perinatal outcomes DATA SOURCES: PubMed, Web of Science, Scopus and Embase were searched for relevant articles up to December 2020. Studies reporting prenatal ultrasonographic markers including intra-abdominal bowel dilation (IABD), extra-abdominal bowel dilation (EABD), bowel wall thickness, polyhydramnios, abdominal circumference <5th percentile, gastric dilation (GD) and bowel dilation not otherwise specified (BD-NOS) were included. The primary outcome was prediction of complex gastroschisis; secondary outcomes were length of hospital stay for newborn, time to full enteral feeding, postnatal mortality rate, incidence of necrotising enterocolitis and short bowel syndrome. RESULTS Thirty-six studies were included in this meta-analysis. We found significant associations between complex gastroschisis and IABD (OR=5.42; 95% CI 3.24 to 9.06), EABD (OR=2.27; 95% CI 1.40 to 3.66), BD-NOS (OR=6.27; 95% CI 1.97 to 19.97), GD (OR=1.88; 95% CI 1.22 to 2.92) and polyhydramnios (OR=6.93; 95% CI 3.39 to 14.18). Second trimester IABD and EABD have greater specificity for the prediction of complex gastroschisis than third trimester values with specificity of 95.6% (95% CI 58.1 to 99.7) and 94.6% (95% CI 86.7 to 97.9) for the second trimester IABD and EABD, respectively. CONCLUSION Prenatal ultrasonographic markers, especially the second trimester IABD and EABD, can identify fetuses that develop complex gastroschisis. Furthermore, these specific ultrasonographic markers can identify those babies at the highest risk for severe complications of this congenital anomaly and hence selected for future antenatal interventions.
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Affiliation(s)
- Raphael C Sun
- Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon, USA.,Division of Fetal Therapy and Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Eyal Krispin
- Division of Fetal Therapy and Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Mohan Pammi
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Shayan Mostafaei
- Department of Biostatistics, Faculty of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran (the Islamic Republic of)
| | - Luc Joyeux
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, Leuven, Belgium
| | - Jan Deprest
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, Katholieke Universiteit Leuven, Leuven, Belgium.,Institute of Women's Health, University College London Hospitals, University College London Medical School, London, UK
| | - Sundeep Keswani
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Timothy C Lee
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Alice King
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Michael A Belfort
- Division of Fetal Therapy and Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Division of Fetal Therapy and Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
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The association between fluid restriction and hyponatremia in newborns with gastroschisis. Am J Surg 2021; 221:1262-1266. [PMID: 33714519 DOI: 10.1016/j.amjsurg.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/01/2021] [Accepted: 03/01/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Newborns with gastroschisis require appropriate fluid resuscitation but are also at risk for hyponatremia that may lead to adverse outcomes. The etiology of hyponatremia in gastroschisis has not been defined. METHODS Over a 24-month period, all newborns with gastroschisis in a free-standing pediatric hospital had sodium levels measured from serum, urine, gastric output, and the bowel bag around the eviscerated contents for the first 48 h of life. Total fluid intake and output were measured. Maintenance fluids were standardized at 120 mL/kg/day. Hyponatremia was defined as a serum sodium <132 mEq/L. A logistic regression model was created to determine independent predictors of hyponatremia. RESULTS 28 infants were studied, and 14 patients underwent primary closure. While serum sodium was normal in all patients at birth, 9 (32%) infants developed hyponatremia at a median of 17.4 h of life. On univariate analysis, hyponatremic babies had a greater net positive fluid balance (74.9 vs 114.7 mL/kg, p = 0.001) primarily due to a decrease in total fluid output (p = 0.05). On multivariable regression, a 10 mL/kg increase in overall fluid balance was associated with an increased risk of developing hyponatremia (OR 1.84 [1.23, 3.45], p = 0.016). No differences in the sodium content of urine, gastric, or bowel bag fluid were observed, and sodium balance was equivalent between cohorts. DISCUSSION Hyponatremia in babies with gastroschisis in the early postnatal period was associated with positive fluid balance and decreased fluid output. Prospective studies to determine the appropriate fluid resuscitation strategy in this population are warranted.
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Chabra S, Peterson SE, Cheng EY. Development of a prenatal clinical care pathway for uncomplicated gastroschisis and literature review. J Neonatal Perinatal Med 2021; 14:75-83. [PMID: 32145003 DOI: 10.3233/npm-190277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Gastroschisis is an abdominal wall defect wherein the bowel is herniated into the amniotic fluid. Controversy exists regarding optimal prenatal surveillance strategies that predict fetal well-being and help guide timing of delivery. Our objective was to develop a clinical care pathway for prenatal management of uncomplicated gastroschisis at our institution. METHODS We performed a review of literature from January 1996 to May 2017 to evaluate prenatal ultrasound (US) markers and surveillance strategies that help determine timing of delivery and optimize outcomes in fetal gastroschisis. RESULTS A total 63 relevant articles were identified. We found that among the US markers, intraabdominal bowel dilatation, polyhydramnios, and gastric dilatation are potentially associated with postnatal complications. Prenatal surveillance strategy with monthly US starting at 28weeks of gestational age (wGA) and twice weekly non-stress testing beginning at 32wGA is recommended to optimize fetal wellbeing. Timing of delivery should be based on obstetric indications and elective preterm delivery prior to 37wGA is not indicated. CONCLUSIONS Close prenatal surveillance of fetal gastroschisis is necessary due to the high risk for adverse outcomes including intrauterine fetal demise in the third trimester. Decisions regarding the timing of delivery should take into consideration the additional prematurity-associated morbidity.
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Affiliation(s)
- Shilpi Chabra
- Department of Pediatrics, Division of Neonatology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Suzanne E Peterson
- Department of Obstetrics/Gynecology, Division of Maternal-Fetal Medicine Swedish Medical Center, Seattle, WA, USA
| | - Edith Y Cheng
- Department of Obstetrics/Gynecology, Division of Maternal-Fetal Medicine, Seattle Children's Hospital and University of Washington Medical Center, Seattle, WA, USA
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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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Oakes MC, Porto M, Chung JH. Advances in prenatal and perinatal diagnosis and management of gastroschisis. Semin Pediatr Surg 2018; 27:289-299. [PMID: 30413259 DOI: 10.1053/j.sempedsurg.2018.08.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Gastroschisis is a congenital, ventral wall defect associated with bowel evisceration. The defect is usually to the right of the umbilical cord insertion and requires postnatal surgical correction. The fetus is at risk for complications such as intrauterine growth restriction, preterm delivery, and intrauterine fetal demise. In addition, complex cases, defined by the presence of intestinal complications such as bowel atresia, stenosis, perforation, or ischemia, occur in up to one third of pregnancies affected by gastroschisis. As complex gastroschisis is associated with increased morbidity and mortality, research has focused on the prenatal detection of this high risk subset of cases. The purpose of this review is to discuss the prenatal, diagnostic approach to the identification of gastroschisis, to describe potential signs of complex gastroschisis on prenatal ultrasound, to review current guidelines for antepartum management and delivery planning, and to summarize results of both past and current intervention trials in fetuses with gastroschisis.
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Affiliation(s)
- Megan C Oakes
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Orange, CA, USA
| | - Manuel Porto
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Orange, CA, USA
| | - Judith H Chung
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Orange, CA, USA.
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Amin R, Domack A, Bartoletti J, Peterson E, Rink B, Bruggink J, Christensen M, Johnson A, Polzin W, Wagner AJ. National Practice Patterns for Prenatal Monitoring in Gastroschisis: Gastroschisis Outcomes of Delivery (GOOD) Provider Survey. Fetal Diagn Ther 2018; 45:125-130. [PMID: 29791899 DOI: 10.1159/000487541] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 02/06/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Gastroschisis is an abdominal wall defect with increasing incidence. Given the lack of surveillance guidelines among maternal-fetal medicine (MFM) specialists, this study describes current practices in gastroschisis management. MATERIALS AND METHODS An online survey was administered to MFM specialists from institutions affiliated with the North American Fetal Therapy Network (NAFTNet). Questions focused on surveillance timing, testing, findings that changed clinical management, and delivery plan. RESULTS Responses were obtained from 29/29 (100%) NAFTNet centers, comprising 143/371 (39%) providers. The majority had a regimen for antenatal surveillance in patients with stable gastroschisis (94%; 134/141). Antenatal testing began at 32 weeks for 68% (89/131) of MFM specialists. The nonstress test (55%; 72/129), biophysical profile (50%; 63/126), and amniotic fluid index (64%; 84/131) were used weekly. Estimated fetal weight (EFW) was performed monthly by 79% (103/131) of providers. At 28 weeks, abnormal EFW (77%; 97/126) and Doppler ultrasound (78%; 99/127) most frequently altered management. In stable gastroschisis, 43% (60/140) of providers delivered at 37 weeks, and 29% (40/ 140) at 39 weeks. DISCUSSION Gastroschisis management differs among NAFTNet centers, although the majority initiate surveillance at 32 weeks. Timing of delivery still requires consensus. Prospective studies are necessary to further optimize practice guidelines and patient care.
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Affiliation(s)
- Ruchi Amin
- Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin,
| | - Aaron Domack
- Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joseph Bartoletti
- Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Erika Peterson
- Maternal Fetal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Britton Rink
- Maternal and Fetal Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jennifer Bruggink
- Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Anthony Johnson
- Maternal and Fetal Medicine, University of Texas Health Sciences Center, Houston, Texas, USA
| | - William Polzin
- Maternal and Fetal Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Amy J Wagner
- Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Fraga MV, Laje P, Peranteau WH, Hedrick HL, Khalek N, Gebb JS, Moldenhauer JS, Johnson MP, Flake AW, Adzick NS. The influence of gestational age, mode of delivery and abdominal wall closure method on the surgical outcome of neonates with uncomplicated gastroschisis. Pediatr Surg Int 2018; 34:415-419. [PMID: 29417204 DOI: 10.1007/s00383-018-4233-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2018] [Indexed: 11/29/2022]
Abstract
AIM OF THE STUDY To evaluate if gestational age (GA), mode of delivery and abdominal wall closure method influence outcomes in uncomplicated gastroschisis (GTC). METHODS Retrospective review of NICU admissions for gastroschisis, August 2008-July 2016. Primary outcomes were: time to start enteral feeds (on-EF), time to discontinue parenteral nutrition (off-PN), and length of stay (LOS). MAIN RESULTS A total of 200 patients with GTC were admitted to our NICU. Patients initially operated elsewhere (n = 13) were excluded. Patients with medical/surgical complications (n = 62) were analyzed separately. The study included 125 cases of uncomplicated GTC. There were no statistically significant differences in the outcomes of patients born late preterm (34 0/7-36 6/7; n = 70) and term (n = 40): on-EF 19 (5-54) versus 17 (7-34) days (p = 0.29), off-PN 32 (12-101) versus 30 (16-52) days (p = 0.46) and LOS 40 (18-137) versus 37 (21-67) days (p = 0.29), respectively. Patients born before 34 weeks GA (n = 15) had significantly longer on-EF, off-PN and LOS times compared to late preterm patients: 26 (12-50) days (p = 0.01), 41 (20-105) days (p = 0.04) and 62 (34-150) days (p < 0.01), respectively. There were no significant differences in outcomes between patients delivered by C-section (n = 62) and patients delivered vaginally (n = 63): on-EF 20 (5-50) versus 19 (7-54) days (p = 0.72), off-PN 32 (12-78) versus 33 (15-105) days (p = 0.83), LOS 42 (18-150) versus 41 (18-139) days (p = 0.68), respectively. There were significant differences in outcomes between patients who underwent primary reduction (n = 37) and patients who had a silo (88): on-EF 15 (5-37) versus 22 (6-54) days (p < 0.01), off-PN 28 (12-52) versus 34 (15-105) days (p = 0.04), LOS 36 (18-72) versus 44 (21-150) days (p = 0.04), respectively. CONCLUSION In our experience, late preterm delivery did not affect outcomes compared to term delivery in uncomplicated GTC. Outcomes were also not influenced by the mode of delivery. Patients who underwent primary reduction had better outcomes than patients who underwent silo placement.
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Affiliation(s)
- Maria V Fraga
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Pablo Laje
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - William H Peranteau
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Holly L Hedrick
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Nahla Khalek
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Juliana S Gebb
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Julie S Moldenhauer
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Mark P Johnson
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Alan W Flake
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - N Scott Adzick
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
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Landisch RM, Yin Z, Christensen M, Szabo A, Wagner AJ. Outcomes of gastroschisis early delivery: A systematic review and meta-analysis. J Pediatr Surg 2017; 52:1962-1971. [PMID: 28947324 DOI: 10.1016/j.jpedsurg.2017.08.068] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/28/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Elective preterm delivery (EPD) of a fetus with gastroschisis may prevent demise and ameliorate intestinal injury. While the literature on optimal timing of delivery varies, we hypothesize that a potential benefit may be found with EPD. METHODS A meta-analysis of publications describing timing of delivery in gastroschisis from 1/1990 to 8/2016 was performed, including studies where either elective preterm delivery (group 1, G1) or preterm gestational age (GA) (group 2, G2) were evaluated against respective comparators. The following outcomes were analyzed: total parenteral nutrition (TPN), first enteral feeding (FF), length of stay, ventilator days, fetal demise, complex gastroschisis, sepsis, and death. RESULTS Eighteen studies describing 1430 gastroschisis patients were identified. G1 studies found less sepsis (p<0.01), fewer days to FF (p=0.03), and 11days less of TPN (p=0.07) in the preterm cohort. Comparatively, G2 studies showed less days to FF in term GA (p=0.02).Whereas G1 BWs were similar, G2 preterm had a significantly lower BW compared to controls (p=0.001). CONCLUSIONS Elective preterm delivery appears favorable with respect to feeding and sepsis. However, benefits are lost when age is used as a surrogate of EPD. A randomized, prospective, multi-institutional trial is necessary to delineate whether EPD is advantageous to neonates with gastroschisis. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Rachel M Landisch
- Division of Pediatric Surgery, Department of Surgery, The Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Ziyan Yin
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Melissa Christensen
- Division of Pediatric Surgery, Department of Surgery, The Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aniko Szabo
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amy J Wagner
- Division of Pediatric Surgery, Department of Surgery, The Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
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Martillotti G, Boucoiran I, Damphousse A, Grignon A, Dubé E, Moussa A, Bouchard S, Morin L. Predicting Perinatal Outcome from Prenatal Ultrasound Characteristics in Pregnancies Complicated by Gastroschisis. Fetal Diagn Ther 2015; 39:279-86. [DOI: 10.1159/000440699] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/25/2015] [Indexed: 11/19/2022]
Abstract
Introduction: The objective of the study was to establish the predictive value of prenatal ultrasound markers for complex gastroschisis (GS) in the first 10 days of life. Material and Methods: In this retrospective cohort study over 11 years (2000-2011) of 117 GS cases, the following prenatal ultrasound signs were analyzed at the last second- and third-trimester ultrasounds: intrauterine growth restriction, intra-abdominal bowel dilatation (IABD) adjusted for gestational age, extra-abdominal bowel dilatation (EABD) ≥25 mm, stomach dilatation, stomach herniation, perturbed mesenteric circulation, absence of bowel lumen and echogenic dilated bowel loops (EDBL). Results: Among 114 live births, 16 newborns had complex GS (14.0%). Death was seen in 16 cases (13.7%): 3 intrauterine fetal deaths, 9 complex GS and 4 simple GS. Second-trimester markers had limited predictive value. Third-trimester IABD, EABD, EDBL, absence of intestinal lumen and perturbed mesenteric circulation were statistically associated with complex GS and death. IABD was able to predict complex GS with a sensitivity of 50%, a specificity of 91%, a positive predictive value of 47% and a negative predictive value of 92%. Discussion: Third-trimester IABD adjusted for gestational age appears to be the prenatal ultrasound marker most strongly associated with adverse outcome in GS.
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Outcomes in infants with prenatally diagnosed gastroschisis and planned preterm delivery. Pediatr Surg Int 2015; 31:1047-53. [PMID: 26399421 DOI: 10.1007/s00383-015-3795-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND The timing and mode of delivery of pregnancies with prenatally diagnosed gastroschisis remains controversial. AIM To evaluate the outcome of patients with gastroschisis managed during two time periods: 2006-2009 and 2010-2014, with planned elective cesarean delivery at 37 versus 35 gestational weeks (gw). A secondary aim was to analyze the outcome in relation to the gestational age at birth. MATERIAL AND METHODS Retrospective review of all cases with gastroschisis managed at our institution between 2006 and 2014. RESULTS Fifty-two patients were identified, 24 during the initial period, and 28 during the second. There were a significantly higher number of emergency cesarean deliveries in the first period. There were no differences between groups with regard to the use of preformed silo, need of parenteral nutrition or length of hospital stay. When analyzing the outcome in relation to the gw the patients actually were born, we observed that patients delivered between 35 and 36.9 gw were primary closed in 88.5% of cases, with shorter time on mechanical ventilation, parenteral nutrition and hospital stay. CONCLUSION Planned caesarian section at 35 completed gestational weeks for fetuses with prenatally diagnosed gastroschisis is safe. We observe the best outcome for patients born between 35 and 36.9 gw.
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Schlueter RK, Azarow KS, Hines AG, Varman M, Abdessalam SF, Raynor SC, Cusick RA. Identifying strategies to decrease infectious complications of gastroschisis repair. J Pediatr Surg 2015; 50:98-101. [PMID: 25598102 DOI: 10.1016/j.jpedsurg.2014.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 10/06/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE We describe the infectious complications of gastroschisis in order to identify modifiable factors to decrease these complications. METHODS Data from 155 gastroschisis patients (2001-2013) were reviewed. Complicated gastroschisis (intestinal atresia, necrotic bowel, or perforation) were excluded, leaving 129 patients for review. Patient demographics, surgical details, postoperative infections and complications, and length of stay were reviewed. We used CDC definitions of infectious complications. RESULTS The average gestational age of patients was 35.97weeks. Silos were used in 46% of patients (n=59) for an average of 7.4days. Thirty-one patients (24%) acquired an infection within the first 60days of life. Patients who developed an infection were born earlier in gestation (P=0.02), weighed less (P=0.01), required silos more often (P=0.01), and received a sutured repair (P=0.04). Length of stay of patients with an infection was longer than in patients without infection (P=0.01). CONCLUSIONS Infectious complications following gastroschisis repair are common. Subsets of gastroschisis patients at increased risk of infection include patients with silos, preterm delivery, low birth weight, and sutured repair. Based on our findings, our recommendation would be to carry gastroschisis patients to term and advocate against the routine use of silos, reserving their use for those cases when primary closure is not possible.
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Affiliation(s)
- Rachel K Schlueter
- University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA
| | - Kenneth S Azarow
- University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA; Oregon Health Sciences University Department of Surgery, Portland, OR, USA
| | - Andrea Green Hines
- University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA
| | - Meera Varman
- Creighton University Pediatric Infectious Diseases, Omaha, NE, USA
| | - Shahab F Abdessalam
- University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA
| | - Stephen C Raynor
- University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA
| | - Robert A Cusick
- University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA.
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Gastroschisis: antenatal sonographic predictors of adverse neonatal outcome. J Pregnancy 2014; 2014:239406. [PMID: 25587450 PMCID: PMC4283398 DOI: 10.1155/2014/239406] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 11/27/2014] [Indexed: 12/31/2022] Open
Abstract
Objectives. The aim of this review was to identify clinically significant ultrasound predictors of adverse neonatal outcome in fetal gastroschisis. Methods. A quasi-systematic review was conducted in PubMed and Ovid using the key terms “gastroschisis,” “predictors,” “outcome,” and “ultrasound.” Results. A total of 18 papers were included. The most common sonographic predictors were intra-abdominal bowel dilatation (IABD), intrauterine growth restriction (IUGR), and bowel dilatation not otherwise specified (NOS). Three ultrasound markers were consistently found to be statistically insignificant with respect to predicting adverse outcome including abdominal circumference, stomach herniation and dilatation, and extra-abdominal bowel dilatation (EABD). Conclusions. Gastroschisis is associated with several comorbidities, yet there is much discrepancy in the literature regarding which specific ultrasound markers best predict adverse neonatal outcomes. Future research should include prospective trials with larger sample sizes and use well-defined and consistent definitions of the adverse outcomes investigated with consideration given to IABD.
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Krebs T, Boettcher M, Schäfer H, Eschenburg G, Wenke K, Appl B, Roth B, Andreas T, Schmitz C, Fahje R, Jacobsen B, Tiemann B, Reinshagen K, Hecher K, Bergholz R. Gut inflammation and expression of ICC in a fetal lamb model of fetoscopic intervention for gastroschisis. Surg Endosc 2014; 28:2437-42. [DOI: 10.1007/s00464-014-3494-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 02/20/2014] [Indexed: 11/30/2022]
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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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