Scheduled preterm delivery for gastroschisis improves postoperative outcome

Abstract

There are some evidence to suggest that careful antenatal monitoring, scheduled preterm delivery and immediate abdominal wall closure may reduce gastroschisis morbidity. We hypothesised that the advantages of a scheduled preterm delivery balance possible complications related to prematurity. A retrospective study was performed including all cases of gastroschisis born between 1990 and 2004 (n = 69). Cases were categorised in two groups. Group 1 contained gastroschisis cases born between 1990 and 1997. Group 2 contained cases occurring since 1997, when a new management pathway for gastroschisis was established: weekly evaluation of the foetal gut by ultrasound (>28 weeks), corticosteroids, and delivery by scheduled caesarean section at 35 weeks (before if evidence of bowel compromise was present). The primary endpoints of this study were the initiation of oral feeding and the number of re-operation for intestinal obstruction. There was a significantly faster initiation of oral feeding (P < 0.0001), however, duration of parenteral nutrition (34 vs. 38 days) and hospital discharge (53 vs. 58.5 days) was not reduced. There was no complication due to prematurity in group 2. Postoperative outcome was improved with less need for muscular stretching or prosthetic patch and less re-operation for intestinal obstruction (P < 0.05). Scheduled and elective preterm delivery facilitates surgical procedure and shortens the time to first feeding. A delivery at 35 weeks (preferring vaginal delivery) seems to be a good compromise between risks related to prematurity and complications related to intestinal peel.

Effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes

“…We also observed that patients treated in the more recent years of the 10-year study period had significantly earlier initiation of enteral feeds and earlier discontinuation of PN than those in the earlier years. The observation that overall outcomes have improved over time may be attributable to improvements in neonatal critical care or more aggressive initiation of enteral feeds and suggests that comparative studies using historical controls should be interpreted with caution [11,12]. In accordance with a large body of existing literature, we did not observe any effects of delivery mode on outcome [13,14].…”

Expectant Management Compared With Elective Delivery at 37 Weeks for Gastroschisis

“…22,23 Several studies have suggested the possibility of reducing intestinal damage by either amnioexchange during the third trimester 24 or early delivery. Some studies have suggested a benefit to limiting the period of intrauterine bowel exposure to amniotic fluid by early delivery, 9,[13][14][15]19 whereas others have failed to show any advantage from such a policy. 8,10,11,[16][17][18]20,[25][26][27][28] In view of reports suggesting an increased risk of stillbirth close to term in fetuses with gastroschisis, 6,7,29,30 our center changed its policy in 1994 to recommend elective induction of labor at 37 weeks of gestation.…”

“…[8][9][10][11][12][13][14][15][16][17][18][19][20][21] Evidence suggests that prolonged amniotic fluid exposure may damage the fetal intestine. 22,23 Inflammatory changes in the bowel tend to occur relatively late in pregnancy and may be attributable to pH changes or increased levels of meconium, urine, or both in the amniotic fluid.…”

Outcomes in infants with prenatally diagnosed gastroschisis and planned preterm delivery

“…Controversy still exists regarding the obstetrical management of pregnancies with gastroschisis, including fetal monitoring [10,12,13], timing and mode of delivery [14][15][16][17][18][19][20][21][22][23][24][25][26]. When some centers advocate for delivery by elective cesarean section [22,26,27] others opt for vaginal delivery [15,28,29] without any differences in outcomes for the infants being observed [15,25,30].…”