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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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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: 0.3] [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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Durmaz LO, Brunner SE, Meinzer A, Krebs TF, Bergholz R. Fetal Surgery for Gastroschisis—A Review with Emphasis on Minimally Invasive Procedures. CHILDREN 2022; 9:children9030416. [PMID: 35327788 PMCID: PMC8947425 DOI: 10.3390/children9030416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/07/2022] [Accepted: 03/12/2022] [Indexed: 11/19/2022]
Abstract
(1) Background: The morbidity of gastroschisis is defined by exposure of unprotected intestines to the amniotic fluid leading to inflammatory damage and consecutive intestinal dysmotility, the viscero-abdominal disproportion which results in an abdomen too small to incorporate the herniated and often swollen intestine, and by associated pathologies, such as in complex gastroschisis. To prevent intestinal damage and to provide for growth of the abdominal cavity, fetal interventions such as amnio exchange, gastroschisis repair or covering have been evaluated in several animal models and human trials. This review aims to evaluate the reported techniques for the fetal treatment of gastroschisis by focusing on minimally invasive procedures. (2) Methods: We conducted a systematic database search, quality assessment and analyzed relevant articles which evaluate or describe surgical techniques for the prenatal surgical management of gastroschisis in animal models or human application. (3) Results: Of 96 identified reports, 42 eligible studies were included. Fetal interventions for gastroschisis in humans are only reported for EXIT procedures and amnio exchange. In animal models, particularly in the fetal sheep model, several techniques of open or minimally invasive repair of gastroschisis or covering the intestine have been described, with fetoscopic covering being the most encouraging. (4) Discussion: Although some promising minimally invasive techniques have been demonstrated in human application and animal models, most of them are still associated with relevant fetal morbidity and mortality and barely appear to be currently applicable in humans. Further research on specific procedures, instruments and materials is needed before any human application.
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Affiliation(s)
- Lidya-Olgu Durmaz
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Kiel Campus, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (L.-O.D.); (S.E.B.); (A.M.); (T.F.K.)
| | - Susanne Eva Brunner
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Kiel Campus, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (L.-O.D.); (S.E.B.); (A.M.); (T.F.K.)
| | - Andreas Meinzer
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Kiel Campus, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (L.-O.D.); (S.E.B.); (A.M.); (T.F.K.)
| | - Thomas Franz Krebs
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Kiel Campus, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (L.-O.D.); (S.E.B.); (A.M.); (T.F.K.)
- Department of Pediatric Surgery, Children’s Hospital of Eastern Switzerland, Claudiusstrasse 6, 9006 St. Gallen, Switzerland
| | - Robert Bergholz
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Kiel Campus, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (L.-O.D.); (S.E.B.); (A.M.); (T.F.K.)
- Correspondence:
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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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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: 3.6] [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: 1.1] [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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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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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: 1.8] [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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Bauseler A, Funke K, Möllers M, Hammer K, Steinhard J, Borowski M, Müller V, Klockenbusch W, Schmitz R. Outcome of fetuses with gastroschisis after modification of prenatal management strategies. Arch Gynecol Obstet 2015; 294:239-43. [DOI: 10.1007/s00404-015-3961-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/06/2015] [Indexed: 12/13/2022]
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de Buys Roessingh AS, Damphousse A, Ballabeni P, Dubois J, Bouchard S. Predictive factors at birth of the severity of gastroschisis. World J Gastrointest Pathophysiol 2015; 6:228-234. [PMID: 26600981 PMCID: PMC4644887 DOI: 10.4291/wjgp.v6.i4.228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/23/2015] [Accepted: 10/27/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To establish children born with gastroschisis (GS).
METHODS: We performed a retrospective study covering the period from January 2000 to December 2007. The following variables were analyzed for each child: Weight, sex, apgar, perforations, atresia, volvulus, bowel lenght, subjective description of perivisceritis, duration of parenteral nutrition, first nasogastric milk feeding, total milk feeding, necrotizing enterocolitis, average period of hospitalization and mortality. For statistical analysis, descriptive data are reported as mean ± standard deviation and median (range). The non parametric test of Mann-Whitney was used. The threshold for statistical significance was P < 0.05 (Two-Tailed).
RESULTS: Sixty-eight cases of GS were studied. We found nine cases of perforations, eight of volvulus, 12 of atresia and 49 children with subjective description of perivisceritis (72%). The mortality rate was 12% (eight deaths). Average duration of total parenteral nutrition was 56.7 d (8-950; median: 22), with five cases of necrotizing enterocolitis. Average length of hospitalization for 60 of our patients was 54.7 d (2-370; median: 25.5). The presence of intestinal atresia was the only factor correlated with prolonged parenteral nutrition, delayed total oral milk feeding and longer hospitalization.
CONCLUSION: In our study, intestinal atresia was our predictive factor of the severity of GS.
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D'Antonio F, Virgone C, Rizzo G, Khalil A, Baud D, Cohen-Overbeek TE, Kuleva M, Salomon LJ, Flacco ME, Manzoli L, Giuliani S. Prenatal Risk Factors and Outcomes in Gastroschisis: A Meta-Analysis. Pediatrics 2015; 136:e159-e169. [PMID: 26122809 DOI: 10.1542/peds.2015-0017] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Gastroschisis is a congenital anomaly with increasing incidence, easy prenatal diagnosis and extremely variable postnatal outcomes. Our objective was to systematically review the evidence regarding the association between prenatal ultrasound signs (intraabdominal bowel dilatation [IABD], extraabdominal bowel dilatation, gastric dilatation [GD], bowel wall thickness, polyhydramnios, and small for gestational age) and perinatal outcomes in gastroschisis (bowel atresia, intra uterine death, neonatal death, time to full enteral feeding, length of total parenteral nutrition and length of in hospital stay). METHODS Medline, Embase, and Cochrane databases were searched electronically. Studies exploring the association between antenatal ultrasound signs and outcomes in gastroschisis were considered suitable for inclusion. Two reviewers independently extracted relevant data regarding study characteristics and pregnancy outcome. All meta-analyses were computed using individual data random-effect logistic regression, with single study as the cluster unit. RESULTS Twenty-six studies, including 2023 fetuses, were included. We found significant positive associations between IABD and bowel atresia (odds ratio [OR]: 5.48, 95% confidence interval [CI] 3.1-9.8), polyhydramnios and bowel atresia (OR: 3.76, 95% CI 1.7-8.3), and GD and neonatal death (OR: 5.58, 95% CI 1.3-24.1). No other ultrasound sign was significantly related to any other outcome. CONCLUSIONS IABD, polyhydramnios, and GD can be used to an extent to identify a subgroup of neonates with a prenatal diagnosis of gastroschisis at higher risk to develop postnatal complications. Data are still inconclusive on the predictive ability of several signs combined, and large prospective studies are needed to improve the quality of prenatal counseling and the neonatal care for this condition.
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Affiliation(s)
- Francesco D'Antonio
- Fetal Medicine Unit, Division of Developmental Sciences, St George's University of London, London, United Kingdom
| | - Calogero Virgone
- Department of Paediatric and Neonatal Surgery, St George's Healthcare National Health Service Trust and University of London, London, United Kingdom
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Roma, Italy
| | - Asma Khalil
- Fetal Medicine Unit, Division of Developmental Sciences, St George's University of London, London, United Kingdom
| | - David Baud
- Materno-Fetal and Obstetrics Research Unit, Department of Obstetrics and Gynaecology, University Hospital, Lausanne, Switzerland
| | - Titia E Cohen-Overbeek
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Marina Kuleva
- Maternité, Hôpital Necker-Enfants Malades, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Laurent J Salomon
- Maternité, Hôpital Necker-Enfants Malades, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Maria Elena Flacco
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy; and EMISAC (Epidemiologia e Management dell'Invecchiamento, e Salubrità degli Ambienti Confinati), CeSI Biotech, Chieti, Italy
| | - Lamberto Manzoli
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy; and EMISAC (Epidemiologia e Management dell'Invecchiamento, e Salubrità degli Ambienti Confinati), CeSI Biotech, Chieti, Italy
| | - Stefano Giuliani
- Department of Paediatric and Neonatal Surgery, St George's Healthcare National Health Service Trust and University of London, London, United Kingdom;
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Abstract
OBJECTIVE To identify perinatal variables associated with adverse outcomes in neonates prenatally diagnosed with gastroschisis. METHODS A retrospective review was conducted of all inborn pregnancies complicated by gastroschisis within the five institutions of the University of California Fetal Consortium from 2007 to 2012. The primary outcome was a composite adverse neonatal outcome comprising death, reoperation, gastrostomy, and necrotizing enterocolitis. Variables collected included antenatal ultrasound findings, maternal smoking or drug use, gestational age at delivery, preterm labor, elective delivery, mode of delivery, and birth weight. Univariate and multivariate analysis was used to assess factors associated with adverse outcomes. We also evaluated the association of preterm delivery with neonatal outcomes such as total parenteral nutrition cholestasis and length of stay. RESULTS There were 191 neonates born with gastroschisis in University of California Fetal Consortium institutions at a mean gestational age of 36 3/7±1.8 weeks. Within the cohort, 27 (14%) had one or more major adverse outcomes, including three deaths (1.6%). Early gestational age at delivery was the only variable identified as a significant predictor of adverse outcomes on both univariate and multivariate analysis (odds ratio 1.4, 95% confidence interval 1.1-1.8 for each earlier week of gestation). Total parenteral nutrition cholestasis was significantly more common in neonates delivered at less than 37 weeks of gestation (38/115 [33%] compared with 11/76 [15%]; P<.001). CONCLUSION In this contemporary cohort, earlier gestational age at delivery is associated with adverse neonatal outcomes in neonates with gastroschisis. Other variables, such as antenatal ultrasound findings and mode of delivery, did not predict adverse neonatal outcomes.
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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: 29] [Impact Index Per Article: 2.6] [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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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: 4.3] [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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Rittler M, Vauthay L, Mazzitelli N. Gastroschisis is a defect of the Umbilical ring: Evidence from Morphological evaluation of stillborn fetuses. ACTA ACUST UNITED AC 2013; 97:198-209. [DOI: 10.1002/bdra.23130] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Revised: 02/23/2013] [Accepted: 02/26/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Monica Rittler
- Medical Genetics Section, Department of Neonatology, Hospital Materno Infantil Ramón Sardá; University of Buenos Aires; Argentina
| | - Liliana Vauthay
- Department of Cell Biology, Histology, Embryology, and Genetics; School of Medicine; University of Buenos Aires; Argentina
| | - Nancy Mazzitelli
- Pathology Unit, Department of Diagnostics, Hospital Materno Infantil Ramón Sardá; University of Buenos Aires; Argentina
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Abstract
Between 2% and 3% of pregnancies are complicated by fetal anomalies. For most anomalies, there is no advantage to late preterm or early-term delivery. The risks of maternal or fetal complication are specific for each anomaly. Very few anomalies pose potential maternal risk. Some anomalies carry ongoing risks to the fetus, such as an increased risk of fetal death, hemorrhage, or organ damage. In a limited number of select cases, the advantages of late preterm or early-term birth may include avoiding an ongoing risk of fetal death related to the anomaly, allowing delivery in a controlled setting with availability of subspecialists and allowing direct care for the neonate with organ injury. The optimal gestational age for delivery cannot be determined for all pregnancies complicated by fetal anomalies. For most pregnancies complicated by anomalies, there is no change to obstetrical management regarding timing of delivery. For those that may benefit from late preterm or early-term delivery, variability exists such that each management plan should be individualized.
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Affiliation(s)
- Sabrina D Craigo
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA 02111, USA.
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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: 1.9] [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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Brugger PC, Prayer D. Development of gastroschisis as seen by magnetic resonance imaging. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:463-470. [PMID: 21105024 DOI: 10.1002/uog.8894] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/29/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To describe the magnetic resonance imaging (MRI) morphology and fetal development of gastroschisis. METHODS Twenty-seven fetal MRI studies of 24 fetuses (mean gestational age 30 (range, 21-38) weeks), with gastroschisis were retrospectively analyzed. The extra- and intra-abdominal positions of the abdominal organs were assessed on T1- and T2-weighted and steady-state free-precession sequences with emphasis on the intra-abdominal findings. RESULTS Third-trimester fetuses (n = 16) showed a uniform morphology: the extracorporeal bowel included jejunum, ileum and colon except for parts of the sigmoid and the rectum. Intra-abdominally the stomach was in contact with the left-sided urinary bladder in 15 of these. Second-trimester fetuses (n = 8) differed with respect to the amount of intra-abdominal bowel and had longer sections of the colon and jejunum intra-abdominally. Intrauterine follow-up (n = 3) demonstrated exteriorization of these bowel segments. Three third-trimester fetuses with gastroschisis complicated by small bowel obstruction, in addition to the dilated small bowel loops, had variable lengths of intra-abdominal colon. CONCLUSIONS Fetal development of gastroschisis is a dynamic process lasting until birth. The typical morphology of gastroschisis changes from the second to the third trimester, since intra-abdominal bowel becomes eventrated by the end of the second trimester. This process of eventration is stopped in cases of intestinal stenosis/atresia caused by narrowing of the abdominal wall defect, resulting in different lengths of intra-abdominal bowel. The time when this occurs may correlate with the amount of viable bowel in cases of intestinal atresia. The concept presented here explains the findings in closing gastroschisis.
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Affiliation(s)
- P C Brugger
- Centre for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria.
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Garcia L, Brizot M, Liao A, Silva MM, Tannuri AC, Zugaib M. Bowel dilation as a predictor of adverse outcome in isolated fetal gastroschisis. Prenat Diagn 2010; 30:964-9. [DOI: 10.1002/pd.2596] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Mears AL, Sadiq JM, Impey L, Lakhoo K. Antenatal bowel dilatation in gastroschisis: a bad sign? Pediatr Surg Int 2010; 26:581-8. [PMID: 20419378 DOI: 10.1007/s00383-010-2600-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2010] [Indexed: 01/05/2023]
Abstract
AIM Foetal bowel dilatation in gastroschisis is traditionally taken to be an indicator of poor prognosis and parents are counselled accordingly. Increased bowel distension is often a factor in the decision for early delivery. The aim of this study was to establish whether a correlation exists between antenatally detected bowel dilatation and the postnatal outcome for babies with gastroschisis. METHODS Antenatal ultrasound scans and subsequent postnatal notes were reviewed for cases of isolated gastroschisis from 2004 to 2008. Bowel dilatation was defined as >10 mm diameter. The type (intra- and/or extra-abdominal dilatation), maximum bowel diameter and gestation at which bowel dilatation was first seen was recorded. Outcome measures included number of days of TPN, type of closure (primary or delayed) and postnatal complications. RESULTS There were 60 antenatal cases of gastroschisis over 5 years. Postnatal notes of 47 were obtained. 38 (81%) had antenatal bowel dilatation, 9 did not. Of those with bowel dilatation, 24 underwent primary closure, 9 required silos, 2 a patch and 3 stomas. Seven (15%) had bowel atresia or necrosis. Three died: NEC, septicaemia and CMV hepatitis. The average time on TPN for those without major complications was 22 days. Of those with no bowel dilatation, 4 had primary closure, 3 a silo, 1 a patch and 1 a stoma. Two had complications requiring further surgery, including one atresia resulting in short gut syndrome. There were no deaths. The mean number of days on TPN was 23. The results also demonstrated no significant correlation between gestation when dilatation was first seen, or degree of dilatation, or both these factors combined, and time of TPN requirement. CONCLUSION These results do not support the current practice of using antenatal bowel dilatation as a prognostic indicator.
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Affiliation(s)
- Alice L Mears
- Department of Paediatric Surgery, Level 2 Children's Hospital, Oxford and University of Oxford, Headley Way, Oxford OX3 9DU, UK
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Contro E, Fratelli N, Okoye B, Papageorghiou A, Thilaganathan B, Bhide A. Prenatal ultrasound in the prediction of bowel obstruction in infants with gastroschisis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 35:702-707. [PMID: 20069663 DOI: 10.1002/uog.7514] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To assess the value of prenatal ultrasound in predicting bowel obstruction requiring surgery in fetuses with prenatal diagnosis of gastroschisis. METHODS The database of our center was searched for cases with an antenatal diagnosis of gastroschisis. The ultrasound images were reviewed blindly to assess the presence of intra- or extra-abdominal bowel dilatation. Details of surgical procedures were noted and the discharge letters were obtained. Pediatric follow-up was also obtained from pediatric surgeons, general practitioners or parents. RESULTS In the 10-year period between November 1998 and September 2008 there were 62 cases with a prenatal diagnosis of gastroschisis. Postnatal outcome was not available for five cases, four pregnancies underwent termination and intrauterine fetal demise occurred in five cases. A final population of 48 liveborn infants was available for analysis. Intra-abdominal bowel dilatation was identified in 14 of these 48 fetuses (29.2%) and extra-abdominal bowel dilatation in 30 (62.5%) fetuses on prenatal ultrasound images. Eight fetuses (16.7%) had bowel obstruction. The relative risk of bowel obstruction with intra-abdominal bowel dilatation was 4.05 (95% CI, 1.12-14.70). On the other hand, the relative risk of bowel obstruction with extra-abdominal bowel dilatation was 1.0 (95% CI, 0.37-3.70). Four babies died, two of whom had intra- and one had extra-abdominal bowel dilatation. CONCLUSIONS Intra-abdominal dilatation of the bowel on prenatal ultrasound examination appears to predict postnatal bowel obstruction and the need for surgical resection. Extra-abdominal bowel dilatation is observed frequently on prenatal ultrasound scans, but is not predictive of bowel obstruction.
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Affiliation(s)
- E Contro
- Academic Department of Obstetrics and Gynaecology, St George's Hospital Medical School, London, UK
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Chung JH, Norton C, Emil S. Sour grapes: ultrasound abnormalities spurred delivery and neonatal surgery. Am J Obstet Gynecol 2009; 201:332.e1-2. [PMID: 19398096 DOI: 10.1016/j.ajog.2009.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Revised: 01/19/2009] [Accepted: 02/20/2009] [Indexed: 10/20/2022]
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Houben C, Davenport M, Ade-Ajayi N, Flack N, Patel S. Closing gastroschisis: diagnosis, management, and outcomes. J Pediatr Surg 2009; 44:343-7. [PMID: 19231531 DOI: 10.1016/j.jpedsurg.2008.10.084] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/23/2008] [Indexed: 12/16/2022]
Abstract
PURPOSE Gastroschisis (GS) is defined as a full-thickness abdominal wall defect (usually right-sided) with intestinal prolapse and occasionally other viscera. The defect itself may close around the viscera causing exit or entry level intestinal atresia and ischaemia or midgut infarction, previously described as closed GS. We now report the largest series of infants born with various stages of closing GS describing features, management, and outcome. METHODS The study used a single-centre retrospective review of infants with GS and evidence of defect closure at birth. RESULTS Nine infants (6 girls) with a median of 35 (range, 32-36) weeks of gestation fulfilled criteria for closing GS from a series of 146 (6%) infants born from August 1994 to December 2007. Delivery had been expedited in 6 based on increasing intraabdominal bowel dilatation and suspicion of closing GS on serial antenatal ultrasound. At delivery, 5 had compromised but viable bowel and required intestinal surgery. Three fetuses, all with midgut necrosis, had antenatal scans typical of GS with no additional features. After a variety of surgical procedures, 7 patients are now fully enterally fed, one is parenteral nutrition-dependent. One died of end-stage liver failure secondary to short bowel syndrome. The length of follow-up was 6 (range, 0.5-11) years. CONCLUSIONS Of infants with GS, 6% present with closing abdominal ring. Close antenatal monitoring may prevent severe bowel loss in some cases. After multiple surgical interventions, most have a favorable outcome.
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Affiliation(s)
- Chris Houben
- Department of Paediatric Surgery, King's College Hospital, London, United Kingdom.
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