Gastroschisis: preterm or term delivery?

Elective Delivery versus Expectant Management for Gastroschisis: A Systematic Review and Meta-Analysis

INTRODUCTION

 The optimal timing of delivery for pregnancies complicated by prenatally diagnosed gastroschisis remains controversial. Therefore, the aim of this study was to find whether elective or expectant delivery is associated with improved neonatal outcome.

MATERIALS AND METHODS

 MEDLINE and Embase databases were searched for studies up to 2021 that reported timing of delivery for prenatally diagnosed gastroschisis. A systematic review and meta-analysis were then performed in group 1: moderately preterm (gestational age [GA]: 34-35 weeks) elective delivery versus expectant management after GA 34-35 weeks; and group 2: near-term (GA: 36-37 weeks) elective delivery versus expectant management after GA 36-37 weeks. The following clinical outcomes were evaluated: length of stay (LOS), total parenteral nutrition (TPN) days, bowel morbidity (atresia, perforation, and volvulus), sepsis, time of first feeding, short gut syndrome and respirator days, and mortality.

RESULTS

 Two randomized controlled trials (RCT)s and eight retrospective cohort studies were included, comprising 629 participants. Moderately preterm elective delivery failed to improve clinical outcomes. However, near-term elective delivery significantly reduced bowel morbidity (7.4 vs. 15.4%, relative risk = 0.37; 95% confidence interval [CI]: 0.18, 0.74; p = 0.005; I2 = 0%) and TPN days (mean difference =-13.44 days; 95% CI: -26.68, -0.20; p = 0.05; I2 = 45%) compared to expectant delivery. The mean LOS was 39.2 days after near-term delivery and 48.7 days in the expectant group (p = 0.06).

CONCLUSION

 Based on the data analyzed, near-term elective delivery (GA 36-37 weeks) appears to be the optimal timing for delivery of pregnancies complicated by gastroschisis as it is associated with less bowel morbidity and shorter TPN days. However, more RCTs are necessary to better validate these findings.

Preterm vs term delivery in antenatally diagnosed gastroschisis: a systematic review and meta-analysis

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.

Factors that Influence Longitudinal Growth from Birth to 18 Months of Age in Infants with Gastroschisis

OBJECTIVE

This study aimed to investigate factors that influence growth in infants with gastroschisis.

STUDY DESIGN

Growth parameters at birth, discharge, 6, 12, and 18 months of age were collected from 42 infants with gastroschisis.

RESULTS

The mean z-scores for weight, length, and head circumference were below normal at birth and decreased between birth and discharge. Lower gestational age correlated with a worsening change in weight z-score from birth to discharge (rho 0.38, p = 0.01), but not with the change in weight z-score from discharge to 18 months (rho 0.04, p = 0.81). There was no correlation between the day of life when the enteral feeds were started and the change in weight z-score from birth to discharge (rho 0.12, p = 0.44) or discharge to 18 months (rho -0.15, p = 0.41).

CONCLUSION

Our study demonstrates that infants with gastroschisis experience a significant decline in weight z-score between birth and discharge, and start to catch up on all growth parameters after discharge. Prematurity in gastroschisis infants is associated with a greater risk for weight loss during this time. This information emphasizes the importance of minimizing weight loss prior to discharge in premature infants with gastroschisis and highlights the need for optimal management strategies for these infants.

Gastroschisis. Case report and management in primary care services

Introducción. La gastrosquisis es una enfermedad de baja prevalencia, pero de muy buen pronóstico si se realiza un adecuado manejo inicial. El presente escrito tiene como objetivo realizar una descripción de esta patología, destacando la importancia de su correcto manejo en el primer nivel.Presentación del caso. Neonato a término con hallazgo de gastrosquisis en primer nivel quien fue remitido al servicio de neonatología de una institución de tercer nivel. El infante recibió manejo interdisciplinario y cierre quirúrgico gradual y tuvo evolución favorable tras 3 meses de hospitalización.Discusión. No existe claridad sobre la causa exacta de la gastrosquisis, ya que es una enfermedad multifactorial. Su diagnóstico puede realizarse desde la etapa prenatal mediante la ultrasonografía, un método que posee alta sensibilidad y especificidad para su detección.Conclusión. La gastrosquisis es una enfermedad que para su diagnóstico y tratamiento requiere de personal especializado en primer nivel, lo que garantiza un correcto manejo inicial y evita futuras complicaciones.

Outcomes of gastroschisis early delivery: A systematic review and meta-analysis

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.

A novel approach in the treatment of neonatal gastroschisis: a review of the literature and a single-center experience

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.

Outcomes in infants with prenatally diagnosed gastroschisis and planned preterm delivery

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.

Timing of elective delivery in gastroschisis: a decision and cost-effectiveness analysis

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.

Surgical Treatment Results In Gastroschisis Based On Preterm Delivery Within The 34th Week Of Gestation By Caesarean Section

was to assess the value of the today’s appropriate approach, preterm delivery in the 34th week of gestation by Caesarean section and subsequent surgical intervention at the perinatal center, in daily practice of pediatric surgery with regard to early postoperative and mid-term outcome.

Over the time period of 9 years, all consecutive cases diagnosed with gastroschisis at the perinatal center, University Hospital of Magdeburg, were born by Caesarean section within the 34th week of gestation followed by surgical intervention. The registered data were compared with those published by other groups.

Overall, there were 19 cases through the investigation period from 01/01/2006 to 12/31/2014. The mean duration of gestation was 237.9 days. The mean birth weight was 2,276 g. In all individuals, a primary closure with no artificial material was achieved. The duration of postoperative artificial respiration was 2.3 days. Oral uptake could be initiated on the 10

The data indicate that in case of gastroschisis, primary closure can be more frequently achieved by section within the 34

Identifying strategies to decrease infectious complications of gastroschisis repair

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.

Abdominal wall defects: prenatal diagnosis, newborn management, and long-term outcomes

Omphalocele and gastroschisis represent the most frequent congenital abdominal wall defects a pediatric surgeon is called to treat. There has been an increased reported incidence in the past 10 years mainly due to the diffuse use of prenatal ultrasound. The early detection of these malformations, and related associated anomalies, allows a multidisciplinary counseling and planning of delivery in a center equipped with high-risk pregnancy assistance, pediatric surgery, and neonatology. At present times, closure of defects, even in multiple stages, is always possible as well as management of most of cardiac-, urinary-, and gastrointestinal-associated malformations. The progress, herein discussed, in the care of newborns with abdominal wall defects assures most of them survive and reach adulthood. Some aspects of transition of medical care will also be considered, including fertility and cosmesis.

Validation of the gastroschisis experimental model and the influence of the mother's diet enriched with glutamine in the fetal morphology

PURPOSE

To validate the gastroschisis experimental model in female rats and the effects on the glutamine fetal morphology during pregnancy.

METHODS

Twelve pregnant rats Wistar were separated in two groups: Group I (n = 6 rats, 71 fetuses) took glutamine and Group II (n = 6 rats, 75 fetuses) took isocaloric supplementation. At the 18th day of pregnancy, female rats were taken to hysterotomy and the fetuses which were selected for the act of gastroschisis were partially removed from the womb and by the laparotomy technique, the exclusion of the intestine was done. After that, fetuses were put in the womb cavity again and the rats' abdomen sutured. At the 21st day of pregnancy, date before delivery, by C-section ordinary animals and the ones with gastroschisis were removed and studied separately. The morphometrical parameters studied were the body weight (PC); the intestine weight (PI); the intestine length (CI) and its relations (PI/PC, PI/CI e PC-PI).

RESULTS

The intestine weight (PI) and the intestine length (CI) were different in fetuses with gastroschisis (p<0.05), however no difference between the groups regarding supplementation with glutamine.

CONCLUSIONS

The gastroschisis experimental model is valid and reproducible. The nutritional therapy with glutamine did not change the morphometrical parameters.

Ferritin and bile acid levels during the intrauterine pre-treatment of gastroschisis by serial amnioexchange

We present a case of gastroschisis managed with serial amnioex-changes. Marked decreases were detected in both ferritin and bile acid levels following the procedure. The bowels were not severely affected, as expected. After delivery, single primary closure of the defect was performed. Early enteral feeding and shorter hospital stay were the main outcome measures. Intrauterine pre-treatment of gastroschisis by serial amnioexchange may provide benefits by decreasing the levels of inflammatory products in the amniotic fluid in order to lower the possible risk of bowel damage, and this may help to achieve better surgical and postnatal outcomes.

11-year experience with gastroschisis: factors affecting mortality and morbidity

OBJECTIVE

The aim of the study was the evaluation of patients treated with a diagnosis of gastroschisis and to establish the factors which affected the morbidity and mortality.

METHODS

Twenty-nine patients, managed for gastroschisis during 2000-2010 were reviewed retrospectively. Patients were analysed in respect to gestational age, birth weight, associated anomalies, type of delivery, operative procedures, postoperative complications, total parenteral nutrition (TPN) related complications. The factors affecting mortality and morbidity were determined.

FINDINGS

Associated abnormalities were present in 24% of the patients. Eleven patients underwent elective reduction in the incubator (Bianchi procedure) without anesthesia. Eight patients had delayed reduction with silo and ten patients had primary closure. Although the type of delivery had an effect on morbidity but not mortality, gestational age, birth weight, and the operative procedure performed had no effect on morbidity or mortality. Duration until tolerance of oral intake, and of TPN and hospitalization were found to be statistically significantly shorter in the group of babies delivered by cesarean section.

CONCLUSION

In our study the most important cause of mortality was the abdominal compartment syndrome and multi-organ failure in the early years. Long hospitalization periods and sepsis were the main causes of mortality in recent years.

Advances in surgery for abdominal wall defects: gastroschisis and omphalocele

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

Does staged closure have a worse prognosis in gastroschisis?

INTRODUCTION

Correction of gastroschisis can be accomplished by primary or staged closure. There is, however, no consensus regarding the best approach or criteria to favor one method over the other has been established.

OBJECTIVE

To compare the outcome of primary and staged closure in newborns with gastroschisis using intravesical pressure (IVP) as the decision criterion.

PATIENTS & METHODS

We prospectively analyzed 45 newborns with gastroschisis. An IVP with a threshold of 20 cm H(2)O was used to indicate primary or staged closure, and the outcomes between the two methods were compared.

RESULTS AND DISCUSSION

Newborns in whom primary closure was feasible were born at a lower gestational age. There was no significant difference in the frequency of complications, time to begin oral feeding, length of parenteral nutrition or length of hospital stay. Compared with previous reports, our data showed higher rates of prenatal diagnosis and cesarean delivery, a lower average birth weight, a higher rate of small gestational age babies and a more frequent association with intestinal atresia. Conversely, our data showed a lower rate of postoperative necrotizing enterocolitis and a lower average length of hospital stay.

CONCLUSION

No significant difference was observed in the outcome of newborns who underwent primary closure or staged closure of gastroschisis when using an IVP below 20 cm H(2)O as the criterion for primary closure.