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Obstetrics & Gynecology 1999;94:112-116
© 1999 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

Modern Obstetric Management and Outcome of Infants With Gastroschisis

BRIAN K. RINEHART, MD, DOM A. TERRONE, MD, CHRISTY M. ISLER, MD, J. ELAINE LARMON, MD, KENNETH G. PERRY, Jr, MD and WILLIAM E. ROBERTS, MD

From the Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi.


   Abstract
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Abstract
Materials and Methods
 Results
 Discussion
 References
 
Objective: To determine whether outcomes of infants with gastroschisis differed by mode or site of delivery, diagnostic method, or when maternal-fetal medicine consultation was given.

Methods: Charts of 32 infants born at the University of Mississippi Medical Center or admitted to the neonatal intensive care unit between September 1992 and June 1998 were reviewed for maternal demographic characteristics and neonatal outcomes. Statistical analysis was done using Student t test, analysis of variance, {chi}2, and Kruskal-Wallis test with P < .05 considered statistically significant.

Results: There were no statistically significant differences in neonatal outcomes by method or site of delivery, diagnostic method, or maternal-fetal medicine consultation before delivery. Infants delivered vaginally had higher Apgar scores at 1 and 5 minutes (9 versus 7 and 9 versus 8, respectively, P < .05). Vaginally delivered infants required more days of antibiotic therapy than those delivered abdominally (10 versus 3 days, P < .05) but had a shorter interval to enteral feedings (15 versus 30 days, P < .05).

Conclusion: Outcomes of infants with isolated gastroschisis were not significantly affected by method or site of delivery, diagnostic method, or maternal-fetal surveillance. Although the findings of this investigation were largely negative and the statistical power limited due to the rarity of this fetal disruption, small series of cases of gastroschisis need to be analyzed to resolve current controversies surrounding optimal treatment of gastroschisis.

Gastroschisis is a relatively rare fetal anomaly, occurring in approximately 0.6 to 10 per 100,000 live births1–3 and consisting of a full-thickness abdominal wall defect characteristically to the right of the umbilicus and 2 to 3 cm in length.4 A variable amount of bowel protrudes through the defect and can extend from the stomach to the rectum. Neonatal morbidity associated with gastroschisis includes fetal growth restriction (FGR), bowel atresia, need for hyperalimentation, and bowel resection.5 However, with improved surgical techniques and intensive neonatal care, the survival rate for newborns with gastroschisis is now reported to be greater than 90%.6

Recent investigations attempted to determine whether abdominal delivery was associated with less neonatal morbidity and mortality than vaginal delivery.7–9 It is unclear whether there is any benefit from elective cesarean delivery of infants with gastroschisis without other obstetric indications for operative intervention. There is increased morbidity associated with preterm delivery of fetuses with gastroschisis.2

Other investigators examined outcomes of neonates with gastroschisis born in tertiary care settings compared with similarly affected neonates born at outlying hospitals and transported to tertiary care facilities after stabilization.9–11 Although no evidence supports the routine transfer of those patients to tertiary care centers for delivery, it has become the de facto standard of care in this country.

There is little data to support routine, serial ultrasonographic surveillance of pregnancies complicated by isolated gastroschisis. Although ultrasound can aid in diagnosing growth restriction12 and bowel dilation, both of which are associated with adverse perinatal outcomes,13 there is no evidence that routine surveillance for those findings improves perinatal outcomes.

The first objective of this investigation was to examine outcomes of infants born with gastroschisis and to determine whether route of delivery or delivery in a tertiary care setting affected neonatal morbidity or mortality. The second objective was to determine whether routine maternal-fetal medicine intervention such as serial ultrasound surveillance for FGR and fetal bowel dilation decreased neonatal morbidity.


   Materials and Methods
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Abstract
 Materials and Methods
Results
 Discussion
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Infants delivered at the University of Mississippi Medical Center or transferred to the neonatal intensive care unit with an admission or discharge diagnosis of gastroschisis or abdominal wall defects between September 1992 and June 1998 were identiied by International Classification of Disease 9 codes. Those cases were cross-referenced with records from the University of Mississippi Medical Center Antenatal Diagnostic Unit. Infants with abdominal wall defects other than gastroschisis, such as omphalocele, cloacal extrophy, and prunebelly syndrome, were excluded from analysis.

Charts of mothers and infants were reviewed for maternal demographic data, antepartum and intrapartum treatment, and neonatal outcome. Statistical analysis was done using Student t test, analysis of variance, {chi}2, and Kruskal-Wallis test with P < .05 considered statistically significant.


   Results
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Abstract
 Materials and Methods
 Results
Discussion
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Thirty-four infants with gastroschisis were admitted between September 1992 and June 1998. Two fetuses, one with isolated gastroschisis and one with amniotic band syndrome, were aborted and were excluded from analysis. All pediatric operations were done by a single pediatric surgeon within 24 hours of delivery.

None of the four subgroups analyzed (site of delivery, mode of delivery, method of diagnosis, and prenatal maternal-fetal medicine consultation) were significantly different for maternal age, estimated gestational age at delivery, mode of delivery, birth weight, respiratory distress syndrome, peritonitis, number of days of parenteral feedings, total hospitalization days, or survival to discharge Tables 1Go–4Go).


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  		Table 1. Characteristics of Infants With Gastroschisis by Site of Delivery
 

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  		Table 4. Characteristics of Infants With Gastroschisis by Maternal-Fetal Medicine Consultation
 
When analyzed by site of delivery, infants delivered at tertiary care hospitals were statistically more likely to be diagnosed at an earlier gestational age than those born elsewhere (25.6 ± 8.3 versus 35.3 ± 2.2 weeks, respectively, P < .001). Infants born at nontertiary care institutions were more likely to have their condition diagnosed at delivery (nine of nine, 100%) than those born in tertiary care institutions (eight of 23, 35%, P = .003).

Infants with gastroschisis who were delivered abdominally were more likely to have lower Apgar scores at 1 and 5 minutes (7 and 8, respectively) than those delivered vaginally (9 and 9, respectively, P = .001 and P = .012). Umbilical artery pH was not significantly different between infants delivered vaginally (7.28 ± 0.10) or abdominally (7.27 ± 0.08, P = .811). Vaginally born infants received more days of antibiotic therapy compared with infants delivered abdominally (10 versus 3, P = .04). Infants delivered by cesarean had longer intervals to first parenteral feeding than those delivered vaginally (30 versus 15 days, P = .017).

Infants with gastroschisis diagnosed at delivery were more likely to be born outside of a tertiary care institution (nine of 17, 53% versus zero of 15, 0%, P = .004) and diagnosed at a later gestational age (35.3 ± 1.7 weeks) than those diagnosed by maternal serum screening (20.8 ± 2.2 weeks) or routine ultrasound (20.6 ± 1.6 weeks, P = .004 [Table 3Go]). The prevalence of meconium at the time of delivery was statistically greater in infants diagnosed by maternal serum screening or routine ultrasound than those diagnosed at delivery, and in infants whose mothers had seen a maternal-fetal medicine subspecialist before delivery (Tables 3Go and 4Go).


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  		Table 3. Characteristics of Infants With Gastroschisis by Method of Diagnosis
 

   Discussion
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Abstract
 Materials and Methods
 Results
 Discussion
References
 
In this investigation we found no differences in major indicators of outcome in infants with gastroschisis, despite differences in site of delivery, mode of delivery, method of diagnosis, and interaction with a maternal-fetal medicine subspecialist before delivery. In any study with largely negative findings, the ability of the study to detect statistically significant findings must be addressed. The statistical power of this investigation to detect differences as small as those found is low. To study treatment of rare fetal disruptions and malformations in which large samples are difficult to accrue in a discrete period of time during which patterns of neonatal treatment are consistent, it is necessary to examine smaller samples.

All of the infants whose condition was diagnosed prenatally were delivered at a tertiary care center because of the policy within our maternal-fetal medicine division that encourages delivery of infants with severe anomalies in tertiary care institutions where immediate neonatal intensive care and pediatric subspecialty consultations are available. That policy explains the difference between our findings and those of Stoodley et al,10 who found that 26% of infants born at non-tertiary care facilities had been diagnosed by ultrasound before delivery in settings where delivery and transport of infants was more acceptable. The delivery of eight of 23 (35%) infants whose condition was not diagnosed before delivery can be attributed to the large number of women who delivered at the University of Mississippi Medical Center who received prenatal care outside the institution, and the low rate of acceptance of maternal-serum biochemical screening in our patient population.

There was no statistical difference in average gestational age at delivery for any subgroup analyzed. The average gestational age at delivery was 35 weeks, which indicated a higher-than-average rate of prematurity in those infants. The lack of difference between those diagnosed prenatally and those diagnosed at delivery indicated a high rate of spontaneous preterm delivery. Our results are supported by those of Quirk et al9 and Adra et al,8 who each found an average gestational age at delivery of approximately 36 weeks.

Apgar scores in the vaginally delivered group were significantly higher at 1 and 5 minutes, which might be secondary to the delivery of infants who were not tolerating the labor process by abdominal delivery. There was no difference in arterial cord pH for those two groups, thus, most infants with gastroschisis tolerated labor.

Infants whose gastroschisis was not diagnosed until delivery did not have higher rates of morbidity and mortality. Although there were large, but not statistically significant, differences in the number of days from birth to initial enteral feedings, and the number of days antibiotics were given in the outborn group, neither the survival rate nor the length of total hospitalization were affected. There does not appear to be increased morbidity in infants delivered at non-tertiary care facilities and then transported for surgical correction of abdominal wall defects when rapid reliable transport is available.

Differences in the gestational age at diagnosis and whether the mother was seen by a maternal-fetal medicine subspecialist prenatally were self-evident. Infants who were not diagnosed by ultrasound or maternal serum screening were diagnosed at much later gestational ages and did not have maternal-fetal surveillance before delivery. The difference in the rate of meconium between infants diagnosed at delivery compared with those who had prenatal diagnoses was most likely due to inconsistency in reporting. Most of the infants whose mothers had no prenatal consultation were delivered at outside institutions, and the infants’ admission histories and physical examinations were the only means of assessing the incidence of meconium in that subgroup. Because of the few pregnant women who had surveillance by perinatologists, and the smaller number of cases in which quantitative data on bowel thickening or dilatation were collected, we were unable to evaluate that method in regard to neonatal outcomes.


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  		Table 2. Characteristics of Infants With Gastroschisis by Delivery Method
 

   Footnotes
 
Supported in part by the Vicksburg Hospital Medical Foundation, Vicksburg, Mississippi.

PII S0029-7844(99)00234-3

Received September 28, 1998. Received in revised form December 14, 1998. Accepted January 7, 1999.


   References
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Abstract
 Materials and Methods
 Results
 Discussion
 References
 
1. Paidas MJ, Crombleholme TM, Robertson FM. Prenatal diagnosis and management of the fetus with an abdominal wall defect. Semin Perinatol 1994;18:196–214.[Medline]

2. Simmons M, Georgeson KE. The effect of gestational age at birth on morbidity in patients with gastroschisis. J Pediatr Surg 1996;31: 1060–2.[Medline]

3. Alsulyman OM, Monteiro H, Ouzounian JG, Barton L, Songster GS, Kovacs BW. Clinical significance of prenatal ultrasonographic intestinal dilation in fetuses with gastroschisis. Am J Obstet Gynecol 1996;175:982–4.[Medline]

4. Calzolari E, Bianchi F, Dolk H, Milan M, EUROCAT Working Group. Omphalocele and gastroschisis in Europe: A survey of 3 million births 1980–1990. Am J Med Genetics 1995;58:187–94.[Medline]

5. Fries MH, Filly RA, Callen PW, Goldstein RB, Goldberg JD, Golbus MS. Growth retardation in prenatally diagnosed cases of gastroschisis. J Ultrasound Med 1993;12:583–8.[Abstract]

6. Davies BW, Stringer MD. The survivors of gastroschisis. Arch Dis Child 1997;77:158–60.[Abstract/Free Full Text]

7. Sakala EP, Erhard LN, White JJ. Elective cesarean section improves outcomes of neonates with gastroschisis. Am J Obstet Gynecol 1993;169:1050–3.[Medline]

8. Adra AM, Landy HJ, Nahmias J, Gomez-Marin O. The fetus with gastroschisis: Impact of route of delivery and prenatal ultrasonography. Am J Obstet Gynecol 1996;174:540–6.[Medline]

9. Quirk JG, Fortney J, Collins HB II, West J, Hassad SJ, Wagner C. Outcomes of newborns with gastroschisis: The effects of mode of delivery, site of delivery, and interval from birth to surgery. Am J Obstet Gynecol 1996;174:1134–40.[Medline]

10. Stoodley N, Sharma A, Noblett H, James D. Influence of place of delivery on outcome in babies with gastroschisis. Arch Dis Child 1993;68:321–3.[Abstract]

11. Nicholls G, Upadhyaya V, Gornall P, Buick RG, Corkery JJ. Is specialist centre delivery of gastroschisis beneficial? Arch Dis Child 1993;69:71–3.[Abstract]

12. Raynor BD, Richards D. Growth retardation in fetuses with gastroschisis. J Ultrasound Med 1997;16:13–6.[Abstract]

13. Pryde PG, Bardicef M, Treadwell MC, Klein M, Isada NB, Evans MI. Gastroschisis: Can antenatal ultrasound predict infant outcomes? Obstet Gynecol 1994;84:505–10.[Medline]

14. Lapillone A, Claris O, Harb A, Maguhn-Sacchettoni A, Basson E, Pelizzo G, et al. Prognosis of gastroschisis: Influence of perinatal management. Prenat Neonat Med 1997;2:146–51.

15. Poulain P, Milon J, Fremont B, Proudhan JF, Odent S, Babut JM, et al. Remarks about the prognosis in case of antenatal diagnosis. Eur J Obstet Gynecol Reprod Biol 1994;54:185–90.[Medline]

16. Saller DN Jr, Canick JA, Palomaki GE, Knight GJ, Haddow JE. Second-trimester maternal serum alpha-fetoprotein, unconjugated estriol, and hCG levels in pregnancies with ventral wall defects. Obstet Gynecol 1994;84:852–5.[Abstract/Free Full Text]




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