Gastroschisis

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Gastroschisis

• March 22nd, 2006
• EOPC Journal Club

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Article Source

• Clinical Obstetrics and Gynecology
• Volume 48
• Number 4
• December 2005
• Saada, Julien M.D. et al
• Paris, France

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Introduction

• Definition -
• Abdominal wall defect
• Right side of umbilicus
• Absence of membrane
• Prolapsed bowel loops in amniotic fluid

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Introduction

• Diagnosis
• Prenatal
• Sonography
• Prognosis
• 90 survival
• Morbidity
• Associated factors

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Introduction

• Pathogenesis
• No definite answer yet
• Management
• Debated mode, time and place of delivery
• Recent Advances
• Amnioexchange
• Prevent Inflammation exposure to digestive
  compounds

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Prevalence/Epidemiology

• Total 1-4/10,000 live births
• Sex ratio of 1
• Global increase unknown reason

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Prevalence/Epidemiology

• Risk factors
• Maternal
• Age lt25
• Age lt20 4 times increase
• Primiparas
• Low socioeconomic status
• Drug abuse (Tobacco, EtOH, cocaine)
• Teratogens
• Genetic trisomy 13, 18, 21 monosomy 22

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Pathogenesis

• Premature regression
• 5th - 6th weeks of right omphalomesenteric
  artery/vein
• Failure of mesodermal components
• Intestinal malrotation
• Addition hypothesis-
• Early in utero rupture of umbilical cord hernia

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Pathogenesis

• Associated Bowel Lesions -
• Animal model studies show mechanical and chemical
  causes
• Amniotic fluid sterile inflammation
• SMA compression

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Diagnosis/Sonography

• 2nd Trimester
• Ultrasound
• Showing
• Defect lateral to the
• Umbilical cord

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Diagnosis/Sonography
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Diagnosis/Sonography

• Chromosomal abnormalities / Extra-intestinal
  malformations
• Determine Bowel Wall thickness
• Controversial
• Intraabdominal Bowel Dilation
• Mesenteric vascularization
• Doppler of SMA

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Diagnosis/Sonography

• Associated Malformation
• Hydronephrosis
• Arthrogryposis
• Hypoplastic gallbladder
• Meckel diverticulum
• Oligo-anhydramnios (intrauterine growth
  restriction)
• Table 4 of article

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FHR Monitoring

• Abnormalities seen in 3rd trimester
• May require delivery
• Decreased variability with or without decels.
• Result from torsion/IUGR/Oligohydramnios
• 3rd Trimester cardiotocography
• FHR monitoring associated with reduction in
  neurological complications

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Fetal Therapy

• Amnioinfusion injection of warmed physiological
  saline
• Amnioexhange replacement of warm saline with 11
  volume exchange.
• Need retrospective/prospective study

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Time, Mode and Place

• Mean gestational age 36 - 37 weeks
• Cesarean versus vaginal
• Preterm delivery (lt 36 weeks)
• No advantage - increase time to feed and increase
  LOS
• Location - pediatric surgical facilities

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Time, Mode and Place

• Trends in mode of delivery for gastroschisis
  infants. Snyder CL, St Peter SD.
• Department of Pediatric Surgery, Children's
  Mercy Hospital, Kansas City, Missouri 64108, USA.
• 16 per year increase in the chance of cesarean
  delivery. There has been a significant trend
  toward cesarean delivery in patients with
  gastroschisis treated at our institution.

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Time, Mode and Place

• Mode of Delivery and Neonatal Survival of Infants
  With Isolated Gastroschisis
• Hamisu M. Salihu, Obstet Gynecol 200410467883.
• In this study the mode of delivery was not found
  to be associated with neonatal survival of
  infants with gastroschisis. Preterm birth rather
  than small for gestational age was the predictor
  of neonatal death among gastroschisis infants.

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Postnatal Care

• Surgical Treatment Primary Closure vs Silo
• Group I (Surgery) Group II (Silo) P Values
• No. of Patients 39 26
• Days on ventilator (median) 4 (3-6) 1
  (1-2) lt0.0001
• Days until first feeding 21 /- 3 11 /- lt0.01
• Days until full feeding 34 /- 4 19 /-
  2 lt0.006
• No. receiving paralytics 23 2 lt0.0001
• NEC episodes 7 2 0.7
• Central line infections 19 3 lt0.003
• Maximum bilirubin 7.0 4.5 lt0.03
• Days with central line 39 /- 4 27 /- 3 lt0.05
• Reoperations 12 (31) 4 (15) 0.24
• Days in hospital 40 (24-60) 28.5
  (25-42.3) lt0.2
• P values lt 0.05 considered significant
• Schlatter, et al Journal of Pediatric Surgery,
  Vol. 38, No. 3, 2003 pp 459-464
• Slide taken from Hebertson/Newhouse presentation
  2-2006

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Postnatal Care

• Primary versus delayed closure
• Dependent on intraabdominal pressure
• Use of spring loaded silo associated with
  improved outcome
• Progressive replacement of parenteral nutrition
  by enteral nutrition.

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Prognosis

• Prognosis is dependent mainly upon severity of
  associated problems
• Prematurity
• Intestinal atresia
• Short gut
• Intestinal inflammatory dysfunction
• Prognosis has improved because of maternal
  ultrasound diagnosis and monitoring
• Much improved since the advancements in IV
  nutrition with subsequent conversion to enteral
  feeds

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Prognosis

• Survival rates of 90
• Improved due to prenatal diagnosis
• Dependent upon -
• Ventilation
• Parenteral to enteral nutrition time
• Overall LOS 80 days
• Improved long-term outcomes