Pre-term and particularly pre-labor cesarean section to avoid complications of gastroschisis

Abstract

The marked advantages and merit of pre-term and particularly pre-labor (PTPL) cesarean section (C-section) in the avoidance, and indeed, virtual elimination of severely disabling gastroschisis (GS) complications in infants diagnosed prior to birth by ultrasound has unfortunately remained controversial in the 10 to 12 years since it was first reported and strongly recommended by numerous authors. During this period, GS has remained one of the four major causes of the short-gut syndrome (SGS) in infancy and childhood and a major cause of prolonged, costly, complicated, and hazardous neonatal intensive care unit stays with requirements for total parenteral nutrition (TPN). The most serious and frequent complications of GS in infants born without PTPL C-section are the occurrence of the "peel", which greatly enlarges and rigidifies the eviscerated gut, and of "complicated GS" (intestinal atresia/s, stenosis, necrosis, perforations) (CGS). The "peel" occurs in 100% of these cases and CGS in approximately 20%. "Peel" enlargement and rigidification of eviscerated intestine in the presence of a reduced peritoneal cavity causes great difficulty in covering the eviscerated, enlarged, and rigidified gut with abdominal wall, skin, a prosthesis, etc., and frequently produces gut ischemia from excessive pressure, which may lead to necrotizing enterocolitis (NEC) and SGS as well as prolonged hospital stays. The presence of a "peel" greatly complicates the hazards of dealing with cases of CGS, as resection and anastomosis are virtually impossible in the presence of a "peel." The authors report personal experience with 77 cases of GS dating as far back as 1951; 44 of the infants were born after the onset of labor by vaginal or C-section delivery and all had some degree of "peel" formation. Of 320 cases from the literature (including some of the cases reported here), 61 (19.1%) involved CGS. Of the 33 cases born PT, and especially PL, there were no cases of "peel" and only 1 case of CGS (3.0%). This infant had a single atresia associated with a very small (1 cm) defect in the abdominal wall and no labor-induced "peel," which was easily and successfully repaired by resection and anastomosis. The 6.4-fold reduction in the occurrence of CGS by PTPL C-section (3.0% vs 19.1%) was statistically significant by the chi-square test (P < 0.05), as was the 100% elimination of the disabling "peel." If the single case of CGS associated with a very small defect and no labor or labor-associated "peel" is eliminated, the incidence of CGS in the remaining PTPL group of 32 cases falls to 0 (0% versus 19.1%, P < 0.007). PT and especially PL C-section may be expected to virtually eliminate "peel" formation and CGS and to remove GS as one of the four major causes of SGS. The findings of this report that PT labor prior to PT C-section may result in both "peel" formation and CGS further solidifies the role of labor in the production of both the "peel" and the equally disabling CGS. Failure to appreciate the central role of labor in GS complications has ...

Scheduled preterm delivery for gastroschisis improves postoperative outcome

“…It has been reported that uterine contraction and vaginal delivery can induce intestinal lesions and intestinal rupture [38]. On the other hand, CS may protect the bowel from dystocia, traumatism and microbial contamination [28,[39][40][41][42][43]. Recently, a meta-analysis by Segel et al [44] found that there was no significant relationship between mode of delivery and the rate of primary fascial repair, neonatal sepsis or paediatric mortality.…”

“…In a recent randomised controlled trial of elective preterm delivery, Logghe et al [27] demonstrated that there was no significant benefit from this management. However, in 1999, Moore et al [28] proposed a preterm and particularly a prelabour CS to reduce peel formation and avoid complications of gastroschisis. Many authors [4][5][6][7] proposed that elective preterm delivery (before 35-38 weeks of gestation) using specific ultrasound criteria resulted in improved postoperative outcome without significant morbidity secondary to prematurity (pulmonary, digestive, neurological).…”

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