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Gastroschisis

Gastroschisis March 22nd, 2006 EOPC Journal Club Article Source Clinical Obstetrics and Gynecology Volume 48 Number 4 December 2005 Saada, Julien M.D. et al… Paris, France Introduction Definition - Abdominal wall defect Right side of umbilicus Absence of membrane

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Gastroschisis

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  1. Gastroschisis March 22nd, 2006 EOPC Journal Club

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

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

  4. Introduction • Diagnosis • Prenatal • Sonography • Prognosis • 90% survival • Morbidity • Associated factors

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

  6. Prevalence/Epidemiology • Total: 1-4/10,000 live births • Sex ratio of 1 • Global increase: unknown reason

  7. Prevalence/Epidemiology • Risk factors • Maternal: • Age <25 • Age <20 = 4 times increase • Primiparas • Low socioeconomic status • Drug abuse (Tobacco, EtOH, cocaine) • Teratogens • Genetic: trisomy 13, 18, & 21; monosomy 22

  8. 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

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

  10. Diagnosis/Sonography • 2nd Trimester Ultrasound Showing Defect lateral to the Umbilical cord

  11. Diagnosis/Sonography

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

  13. Diagnosis/Sonography • Associated Malformation: • Hydronephrosis • Arthrogryposis • Hypoplastic gallbladder • Meckel diverticulum • Oligo-anhydramnios (intrauterine growth restriction) • Table 4 of article

  14. 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

  15. Fetal Therapy • Amnioinfusion: injection of warmed physiological saline • Amnioexhange: replacement of warm saline with 1:1 volume exchange. • Need retrospective/prospective study

  16. Time, Mode and Place • Mean gestational age 36 - 37 weeks • Cesarean versus vaginal • Preterm delivery (< 36 weeks) • No advantage - increase time to feed and increase LOS • Location - pediatric surgical facilities

  17. 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.”

  18. Time, Mode and Place • Mode of Delivery and Neonatal Survival of Infants With Isolated Gastroschisis • Hamisu M. Salihu, Obstet Gynecol 2004;104:678–83. • 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.

  19. 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) <0.0001 Days until first feeding 21 +/- 3 11 +/- <0.01 Days until full feeding 34 +/- 4 19 +/- 2 <0.006 No. receiving paralytics 23 2 <0.0001 NEC episodes 7 2 0.7* Central line infections 19 3 <0.003 Maximum bilirubin 7.0 4.5 <0.03 Days with central line 39 +/- 4 27 +/- 3 <0.05 Reoperations 12 (31%) 4 (15%) 0.24* Days in hospital 40 (24-60) 28.5 (25-42.3) <0.2* *P values < 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

  20. 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.

  21. 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

  22. 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

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