Prenatal diagnosis and management of anterior abdominal wall defects in the west of Scotland

Acute Bowel Ischemia in a Premature Neonate with Miller-Dieker Syndrome and Anomalous Right Coronary Artery From the Pulmonary Artery

Miller-Dieker syndrome (MDS) is a rare disease characterized by type I lissencephaly, craniofacial dysmorphisms, intellectual disability, seizures, and death in early childhood. We report a case of a premature infant with MDS with an anomalous right coronary artery from the pulmonary artery who developed sudden bowel ischemia. This case prompts the reconsideration of cardiovascular involvement in patients with MDS. In addition, this review highlights key clinical features and reviews the critical manifestations of MDS that persist into childhood. [Pediatr Ann. 2023;52(8):e283-e291.].

Body Stalk Anomaly Complicated by Ectopia Cordis: First-Trimester Diagnosis of Two Cases Using 2- and 3-Dimensional Sonography

INTRODUCTION

Body stalk anomaly is a severe defect of the abdominal wall, characterized by the evisceration of abdominal organs and, in more severe cases, thoracic organs as well. The most serious condition in a body stalk anomaly may be complicated by ectopia cordis, an abnormal location of the heart outside the thorax. The aim of this scientific work is to describe our experience with the prenatal diagnosis of ectopia cordis as part of the first-trimester sonographic screening for aneuploidy.

METHODS

We report two cases of body stalk anomalies complicated by ectopia cordis. The first case was identified during a first ultrasound examination at 9 weeks of gestation. The second was identified during an ultrasound examination at 13 weeks of gestation. Both of these cases were diagnosed using high-quality 2- and 3-dimensional ultrasonographic images obtained by the Realistic Vue and Crystal Vue techniques. The chorionic villus sampling showed that the fetal karyotype and CGH-array were both normal.

RESULTS

In our clinical case reports, the patients, immediately after the diagnosis of a body stalk anomaly complicated by ectopia cordis, opted for the termination of pregnancies.

CONCLUSION

Performing an early diagnosis of a body stalk anomaly that is complicated by ectopia cordis is desirable, considering their poor prognoses. Most of the reported cases in the literature suggest that an early diagnosis can be made between 10 and 14 weeks of gestation. A combination of 2- and 3-dimensional sonography could allow an early diagnosis of body stalk anomalies complicated by ectopia cordis, particularly using new ultrasonographic techniques, the Realistic Vue and the Crystal Vue.

Clinically Relevant Prenatal Ultrasound Diagnosis of Umbilical Cord Pathology

Umbilical cord abnormalities are not rare, and are often associated with structural or chromosomal abnormalities, fetal intrauterine growth restriction, and poor pregnancy outcomes; the latter can be a result of prematurity, placentation deficiency or, implicitly, an increased index of cesarean delivery due to the presence of fetal distress, higher admission to neonatal intensive care, and increased prenatal mortality rates. Even if the incidence of velamentous insertion, vasa praevia and umbilical knots is low, these pathologies increase the fetal morbidity and mortality prenatally and intrapartum. There is a vast heterogeneity among societies’ guidelines regarding the umbilical cord examination. We consider the mandatory introduction of placental cord insertion examination in the first and second trimester to practice guidelines for fetal ultrasound scans. Moreover, during the mid-trimester scan, we recommend a transvaginal ultrasound and color Doppler assessment of the internal cervical os for low-lying placentas, marginal or velamentous cord insertion, and the evaluation of umbilical cord entanglement between the insertion sites whenever it is incidentally found. Based on the pathological description and the neonatal outcome reported for each entity, we conclude our descriptive review by establishing a new, clinically relevant classification of these umbilical cord anomalies.

Changing trend in the management of omphalocoele in a tertiary hospital of a middle-income country

BACKGROUND

The peri-operative management of omphalocoele in low- and middle-income countries is challenging owing to non-availability of neonatal intensive care units and equipment needed for the care of this anomaly.

AIM

This study examined our experience in the management of omphalocoele and compared the pattern and outcome with a similar study from the same centre conducted four decades ago.

METHODS

A retrospective study of neonates managed for omphalocoele from 2003 to 2017 (Group A) was performed. Their demographic characteristics, clinical presentation, management modality and outcome were obtained and statistical analysis was performed to determine the predictors of mortality. The findings were also compared with the findings of a similar study (Group B) published from this centre four decades ago from 1973 to 1978.

RESULTS

A total of 95 patients were managed in Group A and 33 in Group B. Their ages ranged from 1 to 15 days with a median age of 1 day and a median gestational age at birth of 37 weeks (range - 36-43 weeks) in Group A and 5-72 h in Group B. There were 54 (56.8%) boys and 41 (43.2%) girls in Group A and 17 (51.5%) boys and 16 (48.5%) girls in Group B. Rupture of the sac was observed in 18 (18.9%) patients in Group A and 13 (39.4%) in Group B. Operative management was adopted for 55 (57.9%) patients in Group A compared to 14 (42.4%) in Group B. Mortality was recorded in 16 (16.8%) patients in Group A and 16 (48.5%) in Group B. Following further analysis in Group A, management outcome was noted to be significantly associated with the state of the sac (P = 0.011), presence of associated sepsis (P = 0.002) at presentation and management modality (P = 0.048) with only associated sepsis independently predicting mortality.

CONCLUSION

Although epidemiological trend and clinical presentation are still similar, management outcome has improved over the years.

Role of Ultrasound in Body Stalk Anomaly and Amniotic Band Syndrome

Body stalk anomaly (BSA) and amniotic band syndrome (ABS) are rare similar fetal sporadic polymalformative syndromes of unknown etiology, though there are certain differences between them. BSA is a combination of developmental abnormalities involving neural tube, body wall, and the limbs with persistent extra embryonic coelomic cavity. ABS is characterized by the presence of thin membrane-like strands attached to fetal body parts and causing constrictions and amputations. This is a cohort study involving 32,100 patients who were referred for routine antenatal ultrasound scan. The data was entered prospectively into a computer database. The duration of study was 3 years. In our study, ultrasound examination in 86 patients demonstrated ventral wall defects, craniofacial defects, and spinal and limb deformities as isolated or combined abnormalities. In those, 10 patients were suspected/diagnosed as BSA/ABS including a twin of a dichorionic diamniotic gestation. The typical features of body stalk anomaly can be detected by ultrasound by the end of the first trimester, which is important for the patient counselling and management. We are presenting these rare conditions and highlighting the importance of early sonographic imaging in diagnosing and differentiating them from other anterior abdominal wall defects.

Prenatal MRI evaluation of limb-body wall complex

BACKGROUND

The sonographic (US) features of limb-body wall complex have been well documented; however the literature regarding the findings on MRI in limb-body wall complex is scant.

OBJECTIVE

To characterize the prenatal MRI features of limb-body wall complex.

MATERIALS AND METHODS

We performed a retrospective review of all MRI scans of fetuses diagnosed with limb-body wall complex at our institution from 2001 to 2011. Fetuses without correlating US scans or follow-up information were excluded. Three pediatric radiologists blinded to the specific US findings reviewed the prenatal MRIs. Images were evaluated for the organ location and attachment, the body part affected, characterization of the body wall defect, and spinal, limb and umbilical cord abnormalities.

RESULTS

Ten subjects met inclusion criteria. MRI was able to detect and characterize the body part affected and associated abnormalities. All fetuses had ventral wall defects, a small thorax and herniated liver and bowel. The kidneys were extracorporeal in three cases. The extruded organs were attached to the placenta or the uterine wall in all cases. Abnormal spinal curvatures of various degrees of severity were present in all cases. Eight cases had a short, uncoiled cord. Limb anomalies were present in 6 of the 10 cases.

CONCLUSION

We illustrate the common fetal MRI findings of limb-body wall complex. The prenatal diagnosis of limb-body wall complex and the differentiation of this defect from treatable abdominal wall defects are crucial to providing appropriate guidance for patient counseling and management.

Body stalk anomaly in a 9-week pregnancy

Body stalk anomaly is a rare and severe malformation syndrome in which the exact pathophysiology and trigger factors are still unknown. This is a case of a 30-year-old patient who underwent ultrasound at 9 weeks of gestation. It revealed an abnormal location of the inferior body of the embryo in the coelomic space. The findings suggested a short umbilical cord syndrome. In order to confirm the diagnosis, the patient was scheduled for a second ultrasonography at 11 weeks of gestation. The obtained images, confirmed the location of the inferior body in the coelomic space with no visible bladder, absence of the right leg, severe abdominal wall defect, consistent with an omphalocele, and a short 5 mm umbilical cord. These last ultrasonographic findings were consistent with body stalk anomaly. Because of severe malformation incompatible with life, the patient was offered termination of pregnancy. Pathologic examination confirmed the suspected pathology of body stalk anomaly.

Metaanalysis of the prevalence of intrauterine fetal death in gastroschisis

OBJECTIVE

The objective of this study was to review the medical literature that has reported the risk for intrauterine fetal death (IUFD) in pregnancies with gastroschisis.

STUDY DESIGN

We systematically searched the literature to identify all published studies of IUFD and gastroschisis through June 2011 that were archived in MEDLINE, PubMed, or referenced in published manuscripts. The MESH terms gastroschisis or abdominal wall defect were used.

RESULTS

Fifty-four articles were included in the metaanalysis. There were 3276 pregnancies in the study and a pooled prevalence of IUFD of 4.48 per 100. Those articles that included gestational age of IUFD had a pooled prevalence of IUFD of 1.28 per 100 births at ≥36 weeks' gestation. The prevalence did not appear to increase at >35 weeks' gestation.

CONCLUSION

The overall incidence of IUFD in gastroschisis is much lower than previously reported. The largest risk of IUFD occurs before routine and elective early delivery would be acceptable. Risk for IUFD should not be the primary indication for routine elective preterm delivery in pregnancies that are affected by gastroschisis.

Outcome of fetal exomphalos diagnosed at 11-14 weeks of gestation

OBJECTIVE

To determine whether sonographic findings in cases of exomphalos detected at the 11-14-week scan can be used to guide pregnancy management.

METHODS

Retrospective study of cases of exomphalos identified from the Fetal Medicine Unit database, University College London Hospitals between January 1998 and January 2010. Pregnancy and neonatal data were ascertained from maternal and neonatal records. Fetal exomphalos was categorized into three groups: exomphalos associated with other major structural malformation(s), isolated exomphalos with increased nuchal translucency (NT) and isolated exomphalos with normal NT.

RESULTS

A total of 98 cases of exomphalos were identified, of which 45 (45.9%) were associated with other major structural malformation(s), identified antenatally. Isolated exomphalos was found with increased NT in 22 cases (22.4%) and with normal NT in 31 cases (31.6%). Of 80 (81.6%) fetuses that were karyotyped, 43 (53.8%) had a chromosomal abnormality; the most common aneuploidy was trisomy 18 (n = 31; 72.1%). Where exomphalos was associated with other major structural abnormalities, or was isolated with increased NT, the incidence of aneuploidy was high, at 78.9% and 72.2%, respectively. Cases of isolated exomphalos with normal NT were all euploid. In 21 cases (21.4%), exomphalos resolved later in pregnancy and none had apparent abnormalities at birth; isolated exomphalos persisted in only three neonates (3.1%).

CONCLUSIONS

The finding of a major structural abnormality or of increased NT in association with exomphalos in the first trimester implies a high risk of aneuploidy. Parents can be reassured that fetuses with isolated exomphalos and normal NT are likely to be euploid.

Characteristics and perinatal course of prenatally diagnosed fetal abdominal wall defects managed in a tertiary center in Japan

AIMS

To identify the clinical characteristics of fetal abdominal wall defects managed at a single institution and to provide information regarding the most likely clinical course of the affected fetuses.

METHODS

A retrospective review was conducted of 44 fetuses prenatally diagnosed with abdominal wall defects at Kyushu University Hospital between 1990 and 2006.

RESULTS

A total of 11 cases of gastroschisis and 33 cases of omphalocele were found. Preterm delivery was observed in eight of 11 fetuses (72.7%) with gastroschisis and in 14 of 27 fetuses (51.9%) with omphalocele who were not artificially aborted. Intrauterine growth restriction (IUGR) was identified in four of 11 fetuses (36.4%) with gastroschisis and in 13 of 27 fetuses (48.1%) with omphalocele who were not aborted artificially. There was a high rate of associated structural anomalies with omphalocele (26/33). Karyotypic abnormalities were observed in eight of 29 tested fetuses with omphalocele (27.6%). The prognosis for a chromosomally normal fetus with omphalocele appeared to largely depend on the associated structural abnormalities and the gestational age at delivery. Despite the frequent presence of IUGR, the outcome of neonates with gastroschisis was good.

CONCLUSIONS

The possibility of preterm delivery and IUGR should be considered during the management of both omphalocele and gastroschisis. For the management of omphaloceles, chromosomal abnormalities and respiratory insufficiency after birth must also be considered. Timely prenatal diagnosis and the subsequent identification of associated anomalies will improve patient care and will enable clinicians to provide appropriate counseling about the expected course.

Antenatal diagnosis and perinatal care of anterior abdominal wall defects

Improvements in anaesthetic care and postoperative management over the last two decades have significantly improved survival of neonates with ventral abdominal wall defects, from a dismal 47% in 1971, to 96% for both gastroschisis and isolated omphalocele in two recent series. This increased survival has generally been attributed to result from improvements in the pre and postoperative management of these fragile neonates. Specifically, the routine use of total parenteral nutrition, and staged repairs for cases with severe “viscero-abdominal disproportion” have been implicated in a decreased incidence of sepsis, morbidity and mortality. In addition, an appreciation of the wide spectrum of anomalies uniquely associated with gastroschisis and omphalocele have helped improve survival, as each has unique pathophysiologic features that have prognostic implications for the fetus before, during and after delivery.

Omphalocele and gastroschisis: Black-White disparity in infant survival

BACKGROUND

Racial/ethnic variations in the occurrence of abdominal wall defects have been previously noted but it remains poorly understood whether race/ethnicity is a determinant of survival among affected infants.

METHODS

Study was conducted on cases of gastroschisis and omphalocele recorded for the years 1983-1999 at the New York Congenital Malformation Registry. Adjusted and unadjusted hazard ratios were generated from a Proportional Hazards Regression model to compare survival among affected Blacks, Hispanics and Whites. The major end point of analysis was differences in all cause mortality among infants with abdominal wall birth defects across different racial/ethnic groups.

RESULTS

Among the three racial/ethnic groups, 1481 infants were diagnosed with either omphalocele (978 or 66%) or gastroschisis (503 or 34%). Overall infant mortality rate (IMR) was 182 per 1000, with 74% of the deaths occurring within the first 28 days of life. Omphalocele infants had significantly higher infant mortality (IMR = 215 per 1000) than infants with gastroschisis (IMR = 118 per 1000)[p < 0.0001]. Overall, Black infants with abdominal wall defects had lower mortality indices than Whites and Hispanics. However, when considered as separate disease entities, Black infants were twice as likely to survive as compared to Whites if they had omphalocele [Adjusted Hazard Ratio (AHR) = 0.52; 95% Confidence Interval (CI) = 0.37-0.74], and twice as likely to die as Whites if they had gastroschisis instead (AHR = 2.23; 95% CI = 1.16-4.28). For both defect subtypes, Hispanics have risks for infant mortality comparable to Whites.

CONCLUSIONS

The natural history of omphalocele and gastroschisis co-varies with race. Black infants with gastroschisis have worse survival outcomes while those with omphalocele have better chances of survival than their White or Hispanic counterparts.

Surveillance and outcome of fetuses with gastroschisis

OBJECTIVES

Infants with gastroschisis have a high survival rate. However, the rate (10-15%) of intrauterine fetal death (IUFD) is considerable, and the association with fetal distress is well known. The aim of this study was to describe the outcome of fetuses with a prenatal diagnosis of gastroschisis. The impact of correct prenatal diagnosis, surveillance and signs of complicating risk factors were evaluated.

METHODS

All fetuses with prenatally diagnosed gastroschisis at the National Center for Fetal Medicine from January 1988 to August 2002 were registered and prospectively evaluated with regular ultrasound examinations. From 34-36 completed gestational weeks the fetuses were monitored daily to every second day with cardiotocography (CTG).

RESULTS

Gastroschisis was diagnosed in 64 fetuses at a mean gestational age of 19 + 2 weeks. All had normal karyotype. Associated anomalies were found in four cases (6.3%). Three pregnancies (4.7%) were terminated, all for reasons other than gastroschisis. One fetus (1.6%) died in utero. Thirteen fetuses (22%) had abnormal CTG leading to subsequent Cesarean sections. Mean gestational age at delivery was 36 + 1 weeks. Mean birth weight was 2586 g. Thirteen infants (22%) were small for gestational age (SGA). In 15 cases (25%) meconium-stained amniotic fluid was found; 14 of these had abnormal CTG and/or were SGA. Small bowel atresia was found in four infants (6.7%). Four infants died postnatally at the age of 0-9 months.

CONCLUSIONS

CTG surveillance of fetuses with gastroschisis may improve the outcome through detection of fetal distress thereby reducing the risk of IUFD. Other clinical situations of importance that are associated with gastroschisis are described and discussed.

Omphalocele and gastroschisis in the state of New York, 1992-1999

BACKGROUND

Variations in the temporal distribution and risk factors for omphalocele and gastroschisis have been suggested although results have not been conclusive. This study examines the trend and risk factors for both conditions among live births in New York State.

METHODS

Analysis of surveillance data from the New York Congenital Malformation Registry for the years 1992-1999.

RESULTS

Five hundred and ninety-five (595) infants with either omphalocele (287) or gastroschisis (308) were identified. It appeared that the prevalence of gastroschisis was rising from 1992-1999, while prevalence of omphalocele was decreasing. Cases of gastroschisis were clustered among younger mothers while the maternal age distribution among omphalocele infants was U-shaped. As compared to Whites, Black infants were more likely to present with omphalocele (OR = 1.73; 95% confidence interval = 1.28-2.33) and Hispanic infants with gastroschisis (OR = 1.50; 95% CI = 1.12-2.00). For both anomalies, residents of rural New York were significantly at higher risk than those living in urban New York. Twenty-three chromosomal aberrations were detected, all among omphalocele babies. Infant survival was substantially greater among gastroschisis (92%) as compared to omphalocele newborn (81%)[p < 0.0001].

CONCLUSIONS

Prevalence of gastroschisis has been on the rise while that of omphalocele has been declining in New York State. Geographical and racial/ethnic variations were observed, further confirming the notion of different etiologies for the two congenital anomalies.

First-year mortality rates for selected birth defects, Hawaii, 1986-1999

Birth defects have been the leading cause of infant death in the United States for over the last decade. However, there is little population-based data on the first-year mortality rates for many specific birth defects and the factors that may affect these mortality rates. This investigation examined the first-year mortality rates for 54 selected birth defects of various organ systems in Hawaii during 1986-1999 using data from a population-based birth defects registry and evaluated the impact of the presence of chromosomal abnormalities and other structural birth defects and the year of delivery on the mortality rates. Mortality rates varied widely by defect, being highest for anencephaly (100%), trisomy 13 (82%), and trisomy 18 (74%), while no first-year deaths were reported for glaucoma, bladder exstrophy, and persistent cloaca. The majority (36 of 54 or 67%) of the birth defects had a mortality rate of less than 25%. Among the 51 structural birth defects, 38 (75%) had higher first-year mortality rate for cases with chromosomal abnormalities and 42 (82%) had higher first-year mortality rates for cases with other major structural birth defects. The mortality rate among 1986-1992 deliveries was higher than the mortality rate among 1993-1999 deliveries for 37 (69%) of the 54 birth defects. This study indicates that first-year mortality rates vary widely by type of birth defect, although the mortality rate for the majority of birth defects is relatively low. The presence of a chromosomal abnormality or other structural birth defect increases the mortality rate, and mortality rates for the majority of birth defects have declined in Hawaii during the study period.

Prenatal ultrasound diagnosis and management of body stalk anomaly: analysis of nine singleton and two multiple pregnancies

OBJECTIVE

To determine prenatal ultrasonographic features and management of fetuses with body stalk syndrome in singleton and multiple gestations.

METHODS

In a retrospective chart analysis we reviewed all cases with body stalk anomaly diagnosed in our prenatal unit between 1994 and 2001. During this time period we adopted a uniform approach to the investigation of cases of body stalk anomaly, including amniocentesis or chorionic villus sampling (CVS) for fetal karyotyping. A general schematic sonographic examination was performed to search for fetal abnormalities and was followed by detailed two-dimensional and color-coded Doppler echocardiography. Nuchal translucency (NT) measurements were performed before 14 weeks of gestation. Postmortem examinations of fetuses were performed following termination by induction with prostaglandin.

RESULTS

Eleven fetuses with body stalk anomaly were diagnosed, including two multiple pregnancies complicated by discordant body stalk anomaly. The typical ultrasonographic features were a major abdominal wall defect, severe kyphoscoliosis, limb abnormalities, neural tube defects, and a malformed, short umbilical cord with a single artery. None of the fetuses demonstrated craniofacial defects. All placentae that were examined showed evidence of persistence of the extra-embryonic celomic cavity. NT measurements were abnormal in all cases. Fetal karyotyping was normal in ten cases. In one case CVS showed a mosaic trisomy 2 (46,XX/47,XX,+ 2). Selective fetocide was performed in one trichorionic-triamniotic triplet pregnancy in early gestation, which was followed by normal development of the remaining healthy dichorionic-diamniotic twins. In a monochorionic-diamniotic twin pregnancy with one affected fetus ultrasound surveillance showed the normal development of the unaffected twin.

CONCLUSIONS

We present a large series of body stalk anomaly, including multiple gestations, with thoraco- and/or abdominoplacental attachment and without craniofacial defects. This specific phenotype may be explained by embryonic maldevelopment. The typical features of body stalk anomaly can be detected by ultrasound by the end of the first trimester, which is important for patient management. Consequently, this anomaly should be distinguished from other fetal abdominal wall defects.

Evaluation of prenatal ultrasound diagnosis of fetal abdominal wall defects by 19 European registries

OBJECTIVES

To evaluate the current effectiveness of routine prenatal ultrasound screening in detecting gastroschisis and omphalocele in Europe.

DESIGN

Data were collected by 19 congenital malformation registries from 11 European countries. The registries used the same epidemiological methodology and registration system. The study period was 30 months (July 1st 1996-December 31st 1998) and the total number of monitored pregnancies was 690,123.

RESULTS

The sensitivity of antenatal ultrasound examination in detecting omphalocele was 75% (103/137). The mean gestational age at the first detection of an anomaly was 18 +/- 6.0 gestational weeks. The overall prenatal detection rate for gastroschisis was 83% (88/106) and the mean gestational age at diagnosis was 20 +/- 7.0 gestational weeks. Detection rates varied between registries from 25 to 100% for omphalocele and from 18 to 100% for gastroschisis. Of the 137 cases of omphalocele less than half of the cases were live births (n = 56; 41%). A high number of cases resulted in fetal deaths (n = 30; 22%) and termination of pregnancy (n = 51; 37%). Of the 106 cases of gastroschisis there were 62 (59%) live births, 13 (12%) ended with intrauterine fetal death and 31 (29%) had the pregnancies terminated.

CONCLUSIONS

There is significant regional variation in detection rates in Europe reflecting different policies, equipment and the operators' experience. A high proportion of abdominal wall defects is associated with concurrent malformations, syndromes or chromosomal abnormalities, stressing the need for the introduction of repeated detailed ultrasound examination as a standard procedure. There is still a relatively high rate of elective termination of pregnancies for both defects, even in isolated cases which generally have a good prognosis after surgical repair.

Risk factors in congenital abdominal wall defects (omphalocele and gastroschisi): a study in a series of 265,858 consecutive births

The aim of this study was to describe the prevalence at birth of two abdominal wall defects (AWD), omphalocela and gastroschisis and to identify possible etiologic factors. The AWD came from 265,858 consecutive births of known ouome registered in the registry of congenital malformations of Strasbourg for the period 1979 to 1998. Request information on the child, the pregnancy, the parents and the family was obtained for cases and for controls. Hundred five cases with AWD were analysed, 55.2 % were omphalocele and 44.8 % were gastroschisis. The mean prevalence rate for omphalocele was 2.18 per 10,000 and for gastroschisis 1.76 per 10,000. Associated malformations were found in 74.1 % of omphalocele compared with 53.2 % of gastroschisis; 29.3 % of fetuses with omphalocele had an abnormal karyotype, 44,8 % had a recognizable syndrome, association or an unspecified malformation pattern; 51.0 % of fetuses with gastroschisis had additional malformations that were not of chromosomal origin, but 1 case. Antenatal ultrasound examination was able to detect 39 (67.2 %) cases of omphaloceles and 27 (57.4 %) cases of gastroschisis. In 30 (51.7 %) cases of omphalocele and in 7 (14.9 %) cases of gastroschisis parents opted for termination of pregnancy. The overall survival rate was 14 (24.1 %) for omphalocele and 30 (63.8 %) for gastroschisis. Weight, length and head circumference at birth of infants with AWD were less than those of controls. The weight of placenta of infants with AWD was not different from the weight of placenta of controls. Gastroschisis was associated with significantly younger maternal age than omphalocele. Pregnancies with AWD were more often complicated by threatened abortion, oligohydramnios and polyhydramnios. Mothers of children with AWD took more often medication during pregnancy than mothers of controls.

Risk factors for adverse outcome of newborns with gastroschisis in a Brazilian hospital

BACKGROUND/PURPOSE

The aim of this study was to determine the frequency of postoperative death and to identify factors associated with adverse prognosis in cases of gastroschisis managed in a tertiary hospital of Brazil.

METHODS

A retrospective transverse study was conducted including all cases of gastroschisis managed at Instituto Materno-Infantil De Pernambuco (IMIP), Recife, Brazil, between January 1995 and December 1999 (n = 31). Prevalence risk (PR) was determined for several prenatal, intraoperative, and postoperative factors.

RESULTS

Overall mortality rate was 52% (16 cases), and sepsis was the main cause of death (93.8%). Prenatal diagnosis reduced about 70% the risk of death. Preterm and low birth weight babies had about 3 times increase in the risk of death. Risk of death was increased twice among outborn babies, but there was no association with delivery route. Increase in risk of neonatal death was related to these other factors: birth-to-admission interval longer than 2 hours and birth-to-surgery interval longer than 4 hours. Prevalence risk also was greater with staged silo repair, poor clinical conditions before surgery, and when mechanical ventilation was needed.

CONCLUSIONS

A high mortality rate was associated with absence of prenatal diagnosis, prematurity, low birth weight, delivery outside the tertiary center, and delayed surgery, worsening clinical conditions that preclude primary closure and increases need of mechanical ventilation. J Pediatr Surg 36:559-564.

Abdominal wall and umbilical cord anomalies

This article begins with a presentation of the embryology of the anterior abdominal wall and umbilical cord. Abnormal embryology and resulting anomalies are presented in tabular form and later reviewed in chronologic order of embryologic development. Techniques involved in the prenatal diagnosis of these abnormalities are also described.

Epidemiology of abdominal wall defects, Hawaii, 1986-1997

The various types of abdominal wall defects are considered to differ in their etiologies, a hypothesis suggested by differences in their epidemiologies. This study examined the impact of selected demographic factors on abdominal wall defects (omphalocele, gastroschisis, and body stalk anomaly) included in a birth defects registry in Hawaii from 1986-1997. The total prevalence for the various defects were: omphalocele (2.76 per 10,000 births, 95% confidence interval (CI), 2.14-3.50), gastroschisis (3.01, 95% CI, 2. 36-3.77), and body stalk anomalies (0.32, 95% CI, 0.14-0.64). The prevalence increased over the 12-year period for both omphalocele (P = 0.052) and gastroschisis (P = 0.008). Women less than age 20 were at increased risk for a gastroschisis-affected pregnancy, while those age 40 and over were disproportionately more likely to have an omphalocele-affected pregnancy. Pacific Islanders had the lowest risk for omphalocele, whereas Far East Asians were least likely to have gastroschisis. Omphalocele rates were lower outside metropolitan Honolulu, while place of residence did not significantly impact gastroschisis risk. The 1-year survival rate was higher for gastroschisis than for omphalocele (88.5% and 70.7%, respectively), while none of the infants with body stalk anomalies was live-born. The results of this study tend to support the hypothesis of differing etiologies for the studied abdominal wall defects.

Considerations for delivery of infants with congenital abnormalities

The antepartum evaluation of fetuses with congenital anomalies includes consideration of peripartum variables, such as route of delivery, gestational age, and location of each, which may impact eventual outcomes. In this article, the controversies, risks, and benefits surrounding peripartum interventions for various fetal congenital anomalies are discussed.

Can decision analysis help us decide whether ultrasound screening for fetal anomalies is worth it?

Decision analysis is a widely used tool to improve clinical decision making when randomized controlled trials are infeasible, underpowered, or lack generalizability. We performed an exploratory decision analysis of routine second trimester ultrasound to detect fetal anomalies, focusing on the assumptions that would have the greatest impact. Six outcome categories were considered: (1) abnormal ultrasound, anomalous child, (2) abnormal ultrasound, elective abortion of anomalous fetus, (3) abnormal ultrasound, healthy child, (4) abnormal ultrasound, elective abortion of healthy fetus, (5) normal ultrasound, healthy child, and (6) normal ultrasound, anomalous child. Live birth and fetal death rates for nine sonographically detectable anomalies were obtained from the California Birth Defects Monitoring Program. The sensitivity and specificity of ultrasound were estimated through meta-analysis of recent series. Plausible ranges for the probabilities of cesarean delivery and elective abortion, by anomaly, were determined through review of the literature. Standard gamble, willingness-to-pay, and human capital estimates of utility were rescaled for comparability. We found that routine ultrasound appears to be the preferred strategy for most women. This choice is sensitive primarily to the specificity of ultrasound and women's willingness-to-pay for the reassurance of a normal ultrasound.

Outcome of prenatally diagnosed anterior abdominal wall defects

One hundred consecutive cases of confirmed anterior abdominal wall defect, identified prenatally in the Oxford Prenatal Diagnosis Unit over 11 years, were studied. Fifty nine per cent of cases were suspected omphaloceles and 41% suspected gastroschisis. Fifty four per cent of omphaloceles were accompanied by other defects compared with 5% of those with gastroschisis. Overall, 29% of fetuses with omphalocele had an abnormal karyotype, and of those with another abnormality identified on scan (excluding four cases with no karyotype performed), 54% had an abnormal karyotype. Of the 27 cases with suspected isolated omphalocele, 14 were live born, all of whom have survived. If the 11 whose parents opted for termination of pregnancy are excluded, survival to birth was 88%. Six of the suspected isolated omphaloceles have Beckwith Wiedemann syndrome (BWS). Eight (57%) of the live born babies with omphaloceles had major problems up to the age of 2, but only one (7%) has long term major problems. This child has BWS and is deaf. Of the 39 cases of suspected isolated gastroschisis, 33 (85%) pregnancies resulted in live birth and one in neonatal death after surgery. Survival rate (excluding terminated pregnancies) was 97%. Gastroschisis was associated with a younger maternal age than omphalocele (p < 0.001) and lower birthweight centile (p < 0.01). Fifteen per cent of the gastroschisis babies had major problems up to the age of 2 years and 12% long term developmental problems. Ninety three per cent of the omphalocele babies and 88% of those who had gastroschisis have no long term problems. Over the study period there have been major changes in scanning equipment and expertise. Since 1991 no woman with a suspected isolated lesion has opted for termination of pregnancy.

Increase in incidence of gastroschisis in the south west of England in 1995

OBJECTIVE

To describe the incidence of gastroschisis and to identify possible aetiological factors.

DESIGN

A retrospective case review study.

SETTING

The South West Region of England.

POPULATION

All known cases of gastroschisis were identified from the regional fetal medicine, ultrasound, pathology and neonatal surgery, databases. Datasets to be collected were agreed prospectively and included demographic, past medical, family and obstetric information for all pregnancies conceived between January 1987 and December 1995.

RESULTS

In the first eight years the incidence was 1.6/10,000 but in 1995 a highly statistically significant rise to 4.4/10,000 was found (P = 0.0009). The increased incidence was not associated with changes in maternal age, proportion of primigravidae, use of tobacco or illicit drugs, conception while taking the oral contraceptive pill, or an increase in the number of teenage pregnancies. The median maternal age at last menstrual period for pregnancies with gastroschisis was 20.4 years which was much younger than the national average of 28 years. Thirty-seven percent of these conceptions occurred during the first quarter of the year compared with the expected 25%.

CONCLUSIONS

The incidence of gastroschisis has risen to a higher level than previously reported which, despite a marked association with young maternal age at conception, is not due to an increase in the teenage pregnancy rate. As the average length of inpatient stay in the neonatal intensive care unit for cases with this malformation is approximately four weeks, the rise has considerable cost implications. The increasing incidence may also offer opportunities to determine the cause of gastroschisis.

Adverse outcome after prenatal diagnosis of gastroschisis: the role of fetal monitoring

Fifty-seven fetuses with gastroschisis presented between 1982 and 1995 were studied by retrospective review of medical records. There were three late intrauterine deaths (IUD). Fetal distress, as determined by reduced fetal movements or abnormal cardiotopograph (CTG), was encountered in 23 of the 54 liveborn infants (43%), all of whom had delivery expedited either by emergency caesarean section (n = 19) or induction (n = 4). Six infants had abnormal neurological outcome: two died in the neonatal period of severe perinatal brain injury, neonatal fits were observed in four, two of whom developed cerebral palsy, and one died at the age of 7 years. All six of these infants had suffered fetal distress. If the three intrauterine deaths are included, 16% of all cases were associated with abnormal neurological outcome. The introduction of regular CTG monitoring from 32 weeks' gestation in 1990 increased the ability to detect fetal distress twofold. This resulted in a similar increase in obstetric intervention and an associated reduction in adverse neurological outcome. Pregnancies associated with gastroschisis should be considered at significant risk of fetal distress, which itself may culminate in late intrauterine death, neonatal death, or adverse neurological outcome. Careful, repeated fetal monitoring in the third trimester is indicated.

Congenital anterior abdominal wall defects in England and Wales 1987-93: retrospective analysis of OPCS data

OBJECTIVES

Analysis of incidence and characteristics of congenital abdominal wall defects, with special reference to the differences between the incidence of gastroschisis and exomphalos (omphalocele).

DESIGN

Retrospective analysis using data from the Office of Population Censuses and Surveys (recoded to differentiate exomphalos and gastroschisis) and the National Congenital Malformation Notification Scheme.

SETTING

England and Wales, 1987 to 1993.

RESULTS

1043 congenital anterior abdominal wall defects were notified within the seven year study period. Of these, 539 were classified as gastroschisis, 448 as exomphalos, 19 as "prune belly syndrome," and 37 as "unclassified." Gastroschisis doubled in incidence from 0.65 in 1987 to 1.35 per 10,000 total births in 1991, with little further change; the incidence of exomphalos decreased from 1.13 to 0.77 per 10000 births. The overall incidence of notified congenital abdominal wall defects was 2.15 per 10000 total births. Gastroschisis was associated with a lower overall maternal age than exomphalos and with a significantly lower proportion of additional reported congenital malformations (5.0%) than in the cohort with exomphalos (27.4%) (odds ratio 0.14, 95% confidence interval 0.09 to 0.22; P < 0.001). The sex ratio of the two cohorts was the same. The incidence of gastroschisis and exomphalos was higher in the northern regions of England than in the south east of the country.

CONCLUSIONS

The national congenital malformation notification system showed an increasing trend in the incidence of fetuses born with gastroschisis and a progressive decreasing incidence of exomphalos in England and Wales between 1987 and 1993. Although the reasons for this are likely to be multifactorial, a true differential change seems likely. The observed increase in incidence of gastroschisis relative to exomphalos and the differentiation in maternal age have implications for resource management within the NHS and warrant further epidemiological monitoring. Regional differences may be due to a dietary or environmental factor, which requires further study.

Gastroschisis: are prenatal ultrasonographic findings useful for assessing the prognosis?

OBJECTIVE

The objective of this study was to assess various prenatal patterns in correlation with survival and the occurrence of complications of antenatally recognized gastroschisis (G).

MATERIALS AND METHODS

We retrospectively studied 34 cases of G. Mortality and morbidity in the postnatal period were assessed and correlated with the prenatal presence or absence of: (1) bowel and/or stomach dilatation, (2) thickening and/or hyperechogenicity of the intestinal wall, (3) meconium peritonitis (in the abdomen) before 20 weeks of gestation, (4) asymmetrical bowel dilatation, and (5) associated malformations. Morbidity took into account the length of hospitalization and the number of surgical procedures.

RESULTS

The overall survival rate was 94%. Neither bowel nor stomach dilatation was significantly correlated with mortality. However, evidence of intestinal dilatation greater than 17 mm had a positive predictive value of 67% for atresia, with a negative predictive value of 86%. Thickening and/or hyperechogenicity of the bowel wall were not significantly associated with mortality. Meconium peritonitis before 20 weeks and asymmetrical bowel dilatation were not statistically significant because of the small sample size. Twelve patients (35.3%) had postnatal complications, with a mean hospital stay of 127 days. Outcome was not modified by the mode of delivery. Associated extradigestive anomalies were present in 20.6% of cases. Chromosomal anomalies were not seen.

CONCLUSION

The prognosis of prenatally detected G is excellent despite the frequency of small bowel atresia (67%) in the group with postnatal complications. Meconium peritonitis before 20 weeks of gestation and/ or asymmetrical bowel dilatation also appear to be indicators of atresia (2/4, 50%) or high morbidity (3/4, 75%).

Prenatal diagnosis of fetal abdominal wall defects: a retrospective analysis of 44 cases

Forty-four fetal abdominal wall defects, consisting of 31 omphalocoeles, 11 cases of gastroschisis, and two body stalk anomalies (which are excluded from further analysis), were diagnosed at 12-39 weeks (median 26 weeks) of gestation. In 10/31 (32 per cent) cases of omphalocoele and in 4/11 (36 per cent) cases of gastroschisis, multiple congenital anomalies were diagnosed. A normal amount of amniotic fluid was present in 39 cases; in three cases of omphalocoele an abnormal amount of amniotic fluid (polyhydramnios, n = 2; oligohydramnios, n = 1) was seen. Prenatally, intrauterine growth retardation (IUGR) was diagnosed in each type of anomaly only once, although the birth weight was below the tenth centile in 23 per cent of omphalocoeles and in 36 per cent of cases of gastroschisis. An abnormal prenatal karyotpye was established in 5/25 (20 per cent) cases of omphalocoele versus none in the gastroschisis group. In 36 cases an expectant obstetric management was followed, and in six cases of omphalocoele the pregnancies were terminated because of severe multiple anomalies (n = 3) or an abnormal prenatal karyotype (n = 3). The preterm delivery rate (excluding terminations) was 12/25 (48 per cent) in the omphalocoele subgroup versus 8/11 (73 per cent) in the gastroschisis subgroup. The Caesarean section rate was almost identical (19 versus 18 per cent) in both subgroups; the majority (n = 5) were performed to protect the abdominal wall defect. The overall survival rate was 39 per cent in the omphalocoele group; in all surviving infants this was the sole congenital anomaly and in each instance there was a normal karyotype. In the gastroschisis group, 8/11 (72 per cent) infants survived, of which two children also displayed unilateral hydronephrosis.

Impact of antenatal diagnosis on incidence and prognosis in abdominal wall defects

The authors review data from the Congenital Malformation Registry in South East Thames regarding fetal abdominal wall defects. Over 24 months, 80 cases were observed (40 gastroschisis, 40 exomphalos). Live-born infants with gastroschisis had few associated anomalies and an excellent prognosis (83% survival rate). Exomphalos is associated with an increased rate of life-threatening anomalies and chromosomal defects. The latter cases often are terminated prenatally. If these cases are excluded, the 1-year survival rate for liveborn infants with exomphalos is favorable (close to 80%). Fetuses in whom gastroschisis and exomphalos are identified by ultrasonography but who have no associated life-threatening chromosomal anomalies should have a favorable prognosis.

The fetus with gastroschisis: impact of route of delivery and prenatal ultrasonography

OBJECTIVES

Our purpose was (1) to assess the influence of delivery route on neonatal outcome in fetuses with gastroschisis and (2) to correlate ultrasonographic appearance of fetal bowel with immediate postnatal outcome.

STUDY DESIGN

Forty-seven cases (1986 to 1994) were reviewed; three abortions and two stillbirths were excluded. Ultrasonographic appearance of fetal bowel (small bowel dilatation > 10 mm) was evaluated in 27 cases.

RESULTS

Twenty-six infants (61.9%) were delivered vaginally and 16 (38.1%) by cesarean section (11 elective, 5 in labor). Delivery route was not significantly associated with indicators of neonatal outcome (rate of primary closure, postoperative complications, days of parenteral nutrition, days to oral feeding, hospital days, or mortality). When ultrasonographic appearance of fetal bowel was correlated with outcome, fetuses with prenatally dilated bowel had significantly more bowel edema at birth (p=0.038), longer operative time (p=0.013), and higher overall rate of postoperative complications (p=0.037).

CONCLUSIONS

(1) Elective cesarean delivery does not improve neonatal outcome in infants with gastroschisis. (2) Abnormal ultrasonographic appearance of fetal bowel is associated with a more difficult repair and a higher overall incidence of postoperative complications.

Body stalk anomaly: prenatal diagnosis

Body stalk anomaly is a severe body wall defect, with maldevelopment of the hindgut and the presence of a very rudimentary umbilical cord. A case of prenatally-diagnosed body stalk anomaly is presented along with the discussion of the prenatal diagnosis and its management. Autopsy of the fetus showed abnormalities compatible with the maldevelopment of embryonic body folding. Prenatal ultrasonographic diagnosis of body stalk anomaly would permit the early termination of pregnancy or avoidance of surgical intervention.

Body stalk anomaly associated with maternal cocaine abuse

A case of body stalk anomaly diagnosed prenatally by ultrasound during the 24th week of pregnancy in a cocaine abusing mother is presented. Accurate visualization of the fetal organs was difficult due to the severe oligohydramnios caused by premature rupture of membranes, probably related to the cocaine use. The sonographic findings were an omphalocoele, fetal attachment to the placenta, kyphoscoliosis, and absence of a floating umbilical cord. The prenatal diagnosis of the syndrome and the possible relationship with cocaine abuse are discussed.