Biochemical investigations of bowel inflammation in gastroschisis

Gestational Age at Delivery and Neonatal Outcomes among Infants with Gastroschisis in the Children's Hospitals Neonatal Consortium (CHNC)

OBJECTIVE

 The effect of gestational age (GA) on gastroschisis outcomes is unclear and delivery timing varies in practice. We aimed to correlate clinical outcomes of infants with gastroschisis and GA at delivery in the Children's Hospitals Neonatal Consortium (CHNC).

STUDY DESIGN

This was a retrospective multicenter cohort study of infants with gastroschisis admitted to CHNC neonatal intensive care units (NICUs) from 2010 to 2016. Patients were categorized by GA: 32 to 346/7, 35 to 366/7, and ≥37 weeks. Respiratory and feeding interventions, mortality, length of stay, and common complications were compared.

RESULTS

In 2021 for patients with gastroschisis, median GA at delivery was 36.3 weeks (interquartile range [IQR] 35.1, 37.3) and mean birth weight 2,425 g (IQR 2,100, 2,766). Overall mortality was low and there was no difference across GA groups. Infants <35 weeks' gestation had the greatest need for respiratory and feeding interventions. Complications such as medical necrotizing enterocolitis (NEC), cholestasis, and central line-associated blood stream infection were less common in infants ≥37 weeks. Feeding initiation and full feeds were earliest in term infants, compared with infants between 35 and 366/7 weeks, and longest in infants <35 weeks. Prematurity had a significant negative association with breast milk exposure. Enteral feeding tube support at discharge increased with prematurity. Compared with term, infants born between 35 and 366/7 weeks' gestation had a higher incidence of medical NEC and lower exposure to mother's milk at discharge but the need for respiratory interventions or tube feeding at discharge was similar.

CONCLUSION

Premature infants with gastroschisis had more neonatal complications including respiratory interventions, longer NICU stay, longer time to full enteral feeds, and higher need for tube feeds at discharge as compared with those delivered at term. Differences were greatest for those <35 weeks GA. While overall mortality remains low, these results provide additional information about GA at birth in gastroschisis, with no evidence of benefit from preterm delivery.

KEY POINTS

· Respiratory support was greatest for those with <35 weeks gestation.. · NEC and cholestasis increase with prematurity.. · Term infants have better feeding outcomes..

miRNA-143 expression is associated with inflammation and time of exposure to amniotic fluid in experimental gastroschisis

OBJECTIVE

Gastroschisis (GS) is a congenital anomaly in the abdominal wall with the intestinal loops exiting laterally to the umbilicus. The contact of the loops with Amniotic Fluid (AF) causes an inflammatory process in the exposed part, leading to an extended hospital stay and an increased risk of morbidity due to alterations related to intestinal motility. The authors aimed to evaluate the time of exposure to the AF in the experimental GS and to search for potential biomarkers of intestinal inflammation by measuring microRNAs.

METHODS

Rat fetuses were divided into three groups: a) CONTROL, b) GS reared on day 18 (GS = 18), and c) GS reared on day 19.5 (GS = 19) (term = 22 days). On day 21.5, the fetuses were removed for biometric parameters and biochemical analyses: 1) Biometrics: Body and Intestinal Weight (BW, IW), and intestinal-body weight ratio (IW/BW); 2) Descriptive histopathology and 3) miR-143 quantification by real-time Polymerase Chain Reaction (PCR).

RESULTS

BW was higher in CONTROL than GS 18 and G19 (p < 0.05). IW, IW/BW, intestinal water, and mRNA-143 were higher in GS 18 and GS 19 than in CONTROL, and GS 18 was higher than GS 19 (p < 0.05). The average of the inflammation score from the intestinal wall with mucosal inflammation and intra-epithelial lymphocytes shows worst in GS 18 and GS 19 vs. CONTROL (p < 0.05).

CONCLUSIONS

The tissue expression of mRNA-143 and the morphological changes in the intestine of GS worsened according to the time of exposure to AF, which could be a possible marker of fetal intestinal damage.

Optimal timing of delivery for growth restricted fetuses with gastroschisis: A decision analysis

OBJECTIVE

Our objective was to determine the optimal timing of delivery of growth restricted fetuses with gastroschisis in the setting of normal umbilical artery (UA) Dopplers.

METHODS

We designed a decision analytic model using TreeAge software for a hypothetical cohort of 2000 fetuses with isolated gastroschisis, fetal growth restriction (FGR), and normal UA Dopplers across 34-39 weeks of gestation. This model accounted for costs and quality adjusted life years (QALYs) for the pregnant individual and the neonate. Model outcomes included stillbirth, respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), short gut syndrome (SGS), neonatal sepsis, neonatal death, and neurodevelopmental disability (NDD).

RESULTS

We found 38 weeks to be the optimal timing of delivery for minimizing overall perinatal mortality and leading to the highest total QALYs. Compared to 37 weeks, delivery at 38 weeks resulted in 367.98 more QALYs, 2.22 more cases of stillbirth, 2.41 fewer cases of RDS, 0.02 fewer cases of NEC, 1.65 fewer cases of IVH, 0.5 fewer cases of SGS, 2.04 fewer cases of sepsis, 11.8 fewer neonatal deaths and 3.37 fewer cases of NDD. However, 39 weeks were the most cost-effective strategy with a savings of $1,053,471 compared to 38 weeks. Monte Carlo analysis demonstrated that 38 weeks was the optimal gestational age for delivery 51.70% of the time, 39 weeks were optimal 47.40% of the time, and 37 weeks was optimal 0.90% of the time.

CONCLUSION

Taking into consideration a range of adverse perinatal outcomes and cost effectiveness, 38-39 weeks gestation is ideal for the delivery of fetuses with gastroschisis, FGR, and normal UA Dopplers. However, there are unique details to consider for each case, and the timing of delivery should be individualized using shared multidisciplinary decision making.

Gastroschisis Outcomes: Presence of Histologic Chorioamnionitis and the Impact on Time to Full Enteral Feeds and Length of Hospital Stay

OBJECTIVE

 Despite improvements in our ability for early diagnosis and providing supportive care for infants with gastroschisis, it continues to be associated with long length of stay and morbidity. Intestinal dysfunction secondary to chronic inflammatory insult to exposed bowel is well known; however, little research has been done on the impact of acute inflammation in the perinatal period on intestinal function. This study's aim was to investigate the impact of acute chorioamnionitis on the time to achieve full enteral feeds and length of hospital stay.

STUDY DESIGN

 Retrospective chart review of 60 mothers and their infants born with gastroschisis at a Level IV NICU from November 2011 to June 2020 was performed. Infants were divided into two groups based on the presence of histologic chorioamnionitis, and outcomes were compared. The primary outcome was delayed full enteral feeds (full enteral feeds after 28 days of life). The secondary outcomes were differences in their time to achieve full enteral feeds and time to hospital discharge, and prolonged length of hospital stay (discharge after 30 days of life). Univariate and multivariate logistic regression analyses were performed to assess the association between the dependent and the predictor variables.

RESULT

 Of the 60 infants enrolled, 23 (38%) had evidence of histologic chorioamnionitis. The median gestational age was 37 weeks. Fifty-four (90%) infants achieved full enteral feeds, with a median time of 24 days. Median length of hospital stay was 31 days. The presence of histologic chorioamnionitis was not associated with delayed full enteral feeds (odds ratio [OR] = 0.79; 95% confidence interval [CI] = 0.14-4.23; p = 0.80) or prolonged length of hospital stay (OR = 0.45; 95% CI = 0.1-0.23; p = 0.32) in the adjusted analysis.

CONCLUSION

 Acute placental inflammation during the perinatal period does not impact the infant's time to achieve full feeds or prolong their hospital stay. Larger studies are needed to confirm these findings.

KEY POINTS

· Chronic inflammatory injury to exposed bowel in utero is well known in fetuses with gastroschisis.. · Acute inflammatory injury during perinatal period may impact enteral feeding outcomes.. · No impact of acute placental inflammation on time to full enteral feeds..

Is anemia frequently recognized in gastroschisis compared to omphalocele? A multicenter retrospective study in southern Japan

PURPOSE

We compared cases of anemia in gastroschisis versus omphalocele and investigated this clinical question.

METHODS

A multicenter study of five pediatric surgery departments in southern Japan was planned. Sixty patients were collected between 2011 and 2020, with 33 (gastroschisis: n = 19, omphalocele: n = 14) who met the selection criteria ultimately being enrolled. Anemia was evaluated before discharge and at the first outpatient visit.

RESULTS

Despite gastroschisis cases showed more frequent iron administration during hospitalization than omphalocele (p = 0.015), gastroschisis cases tended to show lower hemoglobin values at the first outpatient visit than omphalocele cases (gastroschisis: 9.9 g/dL, omphalocele: 11.2 g/dL). Gastroschisis and the gestational age at birth were significant independent predictors of anemia at the first outpatient visit, (gastroschisis: adjusted odds ratio [OR] 19.00, p = 0.036; gestational age at birth: adjusted OR 0.341, p = 0.028). A subgroup analysis for gastroschisis showed that the ratio of anemia in the 35-36 weeks group (8/10, 80.0%) and the > 37 weeks group (6/6, 100%) was more than in the < 34 weeks group (0/3, 0.0%).

CONCLUSIONS

Gastroschisis may carry an increased risk of developing anemia compared with omphalocele due to the difference of direct intestinal exposure of amnion fluid in utero.

Prenatal ultrasonographic markers for prediction of complex gastroschisis and adverse perinatal outcomes: a systematic review and meta-analysis

OBJECTIVE

We sought to perform a meta-analysis of the predictive value of antenatal ultrasonographic markers of bowel dilation, gastric dilation, polyhydramnios and abdominal circumference that predict complex gastroschisis and adverse perinatal outcomes DATA SOURCES: PubMed, Web of Science, Scopus and Embase were searched for relevant articles up to December 2020. Studies reporting prenatal ultrasonographic markers including intra-abdominal bowel dilation (IABD), extra-abdominal bowel dilation (EABD), bowel wall thickness, polyhydramnios, abdominal circumference <5th percentile, gastric dilation (GD) and bowel dilation not otherwise specified (BD-NOS) were included. The primary outcome was prediction of complex gastroschisis; secondary outcomes were length of hospital stay for newborn, time to full enteral feeding, postnatal mortality rate, incidence of necrotising enterocolitis and short bowel syndrome.

RESULTS

Thirty-six studies were included in this meta-analysis. We found significant associations between complex gastroschisis and IABD (OR=5.42; 95% CI 3.24 to 9.06), EABD (OR=2.27; 95% CI 1.40 to 3.66), BD-NOS (OR=6.27; 95% CI 1.97 to 19.97), GD (OR=1.88; 95% CI 1.22 to 2.92) and polyhydramnios (OR=6.93; 95% CI 3.39 to 14.18). Second trimester IABD and EABD have greater specificity for the prediction of complex gastroschisis than third trimester values with specificity of 95.6% (95% CI 58.1 to 99.7) and 94.6% (95% CI 86.7 to 97.9) for the second trimester IABD and EABD, respectively.

CONCLUSION

Prenatal ultrasonographic markers, especially the second trimester IABD and EABD, can identify fetuses that develop complex gastroschisis. Furthermore, these specific ultrasonographic markers can identify those babies at the highest risk for severe complications of this congenital anomaly and hence selected for future antenatal interventions.

Growth from Birth to 30 months for Infants Born with Congenital Gastrointestinal Anomalies and Disorders

OBJECTIVE

This study aimed to investigate growth among neonates with gastrointestinal disorders.

STUDY DESIGN

Inclusion criteria included neonates with gastroschisis, omphalocele, intestinal atresia, tracheoesophageal fistula, Hirschsprung's disease, malabsorption disorders, congenital diaphragmatic hernia, and imperforate anus born between 2010 and 2018. Anthropometrics were collected for the first 30 months, and a subgroup analysis was performed for gastroschisis infants.

RESULTS

In 61 subjects, 13% developed severe growth failure within the first month. One-, four-, and nine-month weight and length z-scores were less than birth weight in all infants (p < 0.05). In infants with gastroschisis, a similar pattern was observed for weight z-scores only (p < 0.05). From birth to 15 months, head circumference z-score increased over time in all infants (p = 0.001), while in gastroschisis infants, weight, length, and head circumference z-scores increased over time (p < 0.05).

CONCLUSION

In a cohort of infants with gastrointestinal disorders, growth failure was followed by catch-up growth.

Growth Failure Prevalence in Neonates with Gastroschisis : A Statewide Cohort Study

OBJECTIVES

To perform a multicenter study to assess growth failure in hospitalized infants with gastroschisis.

STUDY DESIGN

This study included neonates with gastroschisis within sites in the University of California Fetal Consortium. The study's primary outcome was growth failure at hospital discharge, defined as a weight or length z score decrease >0.8 from birth. Regression analysis was performed to assess changes in z scores over time.

RESULTS

Among 125 infants with gastroschisis, the median gestational age was 37 weeks (IQR 35-37). Length of stay was 32 days (23-60); 55% developed weight or length growth failure at discharge (28% had weight growth failure, 42% had length growth failure, and 15% had both weight and length growth failure). Weight and length z scores at 14 days, 30 days, and discharge were less than birth (P < .01 for all). Weight and length z scores declined from birth to 30 days (-0.10 and -0.11 z score units/week, respectively, P < .001). Length growth failure at discharge was associated with weight and length z score changes over time (P < .05 for both). Lower gestational age was associated with weight growth failure (OR 0.70 for each gestational age week, 95% CI 0.55-0.89, P = .004).

CONCLUSIONS

Growth failure, in particular linear growth failure, is common in infants with gastroschisis. These data suggest the need to improve nutritional management in these infants.

Interval growth across gestation in pregnancies with fetal gastroschisis

BACKGROUND

Gastroschisis is often complicated by fetal growth restriction, preterm delivery, and prolonged neonatal hospitalization. Prenatal management and delivery decisions are often based on estimated fetal weight and interval growth; however, appropriate interval growth from week to week across gestation for these fetuses is poorly understood.

OBJECTIVE

This study aimed to determine the median increase in overall estimated fetal weight and individual biometric measurements across each week of gestation in pregnancies with fetal gastroschisis and to assess whether lower in utero fetal weight gain is predictive of postnatal growth or adverse neonatal outcomes.

STUDY DESIGN

This was a retrospective cohort study of pregnancies with gastroschisis evaluated at 5 institutions of the University of California Fetal-Maternal Consortium from December 2014 to December 2019. The inclusion criteria were prenatally diagnosed gastroschisis with at least 1 ultrasound performed at a University of California Fetal-Maternal Consortium institution. Estimated fetal weight and individual biometric measurements were recorded for each ultrasound performed at a University of California Fetal-Maternal Consortium institution from the time of gastroschisis diagnosis to delivery. Median estimated fetal weight and biometric measurements were calculated for each gestational age in 1-week increments. Neonatal outcomes collected were birthweight, length of stay, complications of gastroschisis (bowel atresia, bowel stricture, ischemic bowel before closure, or severe pulmonary hypoplasia), and growth failure at discharge.

RESULTS

We identified 95 pregnancies with fetal gastroschisis who, in aggregate, had 360 growth ultrasounds at a University of California Fetal-Maternal Consortium institution. The median interval growth was 130 g/wk. The median estimated fetal weight and abdominal circumference in fetal gastroschisis cases were approximately the tenth percentile on the Hadlock growth curve across gestation. Moreover, the median biparietal diameter, head circumference, and femur length measurements remained below the 50th percentile on the Hadlock growth curve across gestation. The median birthweight for neonates with less than the median weekly prenatal weight gain was less than for those with greater than the median weekly prenatal weight gain (2185 g vs 2780 g; P<.01). There was no difference in prenatal weight gain trajectory when comparing neonates who had or did not have bowel complications of gastroschisis.

CONCLUSION

In this multicenter cohort of pregnancies with fetal gastroschisis, the median interval growth was 130 g/wk, and overall, in utero growth closely followed the tenth percentile on the Hadlock curve. Poor prenatal growth in cases of fetal gastroschisis correlates with lower neonatal weights but did not predict a more complicated course.

Abdominal wall defects

Abdominal wall defects are common congenital anomalies with the most frequent being gastroschisis and omphalocele. Though both are the result of errors during embryologic development of the fetal abdominal wall, gastroschisis and omphalocele represent unique disorders that have different clinical sequelae. Gastroschisis is generally a solitary anomaly with postnatal outcomes related to the underlying integrity of the prolapsed bowel. In contrast, omphalocele is frequently associated with other structural anomalies or genetic syndromes that contribute more to postnatal outcomes than the omphalocele defect itself. Despite their embryological differences, both gastroschisis and omphalocele represent anomalies of fetal development that benefit from multidisciplinary and translational approaches to care, both pre- and postnatally. While definitive management of abdominal wall defects currently remains in the postnatal realm, advancements in prenatal diagnostics and therapies may one day change that. This review focuses on recent advancements, novel techniques, and current controversies related to the prenatal diagnosis and management of gastroschisis and omphalocele.

Multiple cytokine analysis in gastroschisis: Association with adverse outcomes including fetal brain damage

OBJECTIVES

To investigate the distribution of multiple cytokines in gastroschisis and reveal its association with clinical outcomes, including gastrointestinal disorders and fetal brain damage caused by chronic inflammation in gastroschisis.

METHODS

We obtained amniotic fluid and arterial cord blood from 10 patients with gastroschisis, and evaluated the profile of 40 cytokines via multiplex immunoassay. The possible relationship of the cytokines with the time taken to attain full enteral nutrition and cord S100B, a surrogate marker of brain damage, was estimated. Associations among the relevant cytokines were also assessed.

RESULTS

Although clinical characteristics in our cohort had no relevance, several cytokines in cord blood, especially IL-2, IL-8, CCL1, CCL7, CXCL1, CXCL2, and CXCL6, were clearly elevated in patients who took a longer time to attain full enteral nutrition, whereas only IL-16 in cord blood was significantly related to cord S100B and strongly correlation with cord S100B levels. Moreover, our data indicated that IL-16 was considerably less correlated with the other cytokines associated with adverse outcomes.

CONCLUSIONS

We investigated the cytokine characteristics of both amniotic fluid and cord blood in gastroschisis, and found that certain cytokines could affect the adverse outcomes, including fetal brain damage. These findings provide important information that could further clarify the pathophysiology of gastroschisis and propose a novel clinical implication of gastroschisis that could be used to predict adverse outcomes, especially neurodevelopmental disorders.

Is there a role for fetal interventions in gastroschisis management? - An updated comprehensive review

We conducted a comprehensive evidence-based review on the epidemiology and current standard of care of gastroschisis management as well as the pathophysiology, rationale and feasibility of fetal therapy as a viable alternative. Gastroschisis is a periumbilical abdominal wall defect characterized by abdominal viscera herniation in utero. It affects 4 in 10 000 live births, but the prevalence has steadily increased in recent years. Gastroschisis is typically diagnosed on routine second-trimester ultrasound. The overall prognosis is favorable, but complex gastroschisis, which accounts for about 10% to 15% of cases, is associated with a higher mortality, significant disease burden and higher healthcare costs due to long- and short-term complications. The current standard of care has yet to be established but generally involves continued fetal surveillance and multidisciplinary perinatal care. Postnatal surgical repair is achieved with primary closure, staged silo closure or sutureless repair. Experimental animal studies have demonstrated the feasibility of in utero closure, antiinflammatory therapy and prenatal regenerative therapy. However, reports of early preterm delivery and amnioinfusion trials have failed to show any benefit in humans. Further experimental studies and human trials are necessary to demonstrate the potential benefit of fetal therapy in gastroschisis.

Elective delivery at 34 weeks vs routine obstetric care in fetal gastroschisis: randomized controlled trial

OBJECTIVE

To evaluate whether elective preterm delivery (ED) at 34 weeks is of postnatal benefit to infants with isolated gastroschisis compared with routine obstetric care (RC).

METHODS

Between May 2013 and September 2015, all women with a sonographic diagnosis of fetal gastroschisis referred to a single tertiary center, before 34 weeks' gestation, were invited to participate in this study. Eligible patients were randomized to ED (induction of labor at 34 weeks) or RC (spontaneous labor or delivery by 37-38 weeks, based on standard obstetric indications). The primary outcome measure was length of time on total parenteral nutrition (TPN). Secondary outcomes were time to closure of gastroschisis and length of stay in hospital. Outcome variables were compared using appropriate statistical methods. Analysis was based on intention-to-treat.

RESULTS

Twenty-five women were assessed for eligibility, of whom 21 (84%; 95% CI, 63.9-95.5%) agreed to participate in the study; of these, 10 were randomized to ED and 11 to RC. The trial was stopped at the first planned interim analysis due to patient safety concerns and for futility; thus, only 21 of the expected 86 patients (24.4%; 95% CI, 15.8-34.9%) were enrolled. Median gestational age at delivery was 34.3 (range, 34-36) weeks in the ED group and 36.7 (range, 27-38) weeks in the RC group. One patient in the ED group delivered at 36 weeks following unsuccessful induction at 34 weeks. Neonates of women who underwent ED, compared to those in the RC group, showed no difference in the median number of days on TPN (54 (range, 17-248) vs 21 (range, 9-465) days; P = 0.08), number of days to closure of gastroschisis (7 (range, 0-15) vs 5 (range, 0-8) days; P = 0.28) and length of stay in hospital (70.5 (range, 22-137) vs 31 (range, 19-186) days; P = 0.15). However, neonates in the ED group were significantly more likely to experience late-onset sepsis compared with those in the RC group (40% (95% CI, 12.2-73.8%) vs 0%; P = 0.03).

CONCLUSION

This study demonstrates no benefit of ED of fetuses with gastroschisis when postnatal gastroschisis management is similar to that used in routine care. Rather, the data suggest that ED is detrimental to infants with gastroschisis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

The origin of amniotic fluid monocytes/macrophages in women with intra-amniotic inflammation or infection

Background Monocytes, after neutrophils, are the most abundant white blood cells found in the amniotic cavity of women with intra-amniotic inflammation/infection. However, the origin of such cells has not been fully investigated. Herein, we determined (1) the origin of amniotic fluid monocytes/macrophages from women with intra-amniotic inflammation/infection, (2) the relationship between the origin of amniotic fluid monocytes/macrophages and preterm or term delivery and (3) the localization of monocytes/macrophages in the placental tissues. Methods Amniotic fluid samples (n = 16) were collected from women with suspected intra-amniotic inflammation or infection. Amniotic fluid monocytes/macrophages were purified by fluorescence-activated cell sorting, and DNA fingerprinting was performed. Blinded placental histopathological evaluations were conducted. Immunohistochemistry was performed to detect CD14+ monocytes/macrophages in the placental tissues. Results DNA fingerprinting revealed that (1) 56.25% (9/16) of amniotic fluid samples had mostly fetal monocytes/macrophages, (2) 37.5% (6/16) had predominantly maternal monocytes/macrophages and (3) one sample (6.25% [1/16]) had a mixture of fetal and maternal monocytes/macrophages. (4) Most samples with predominantly fetal monocytes/macrophages were from women who delivered early preterm neonates (77.8% [7/9]), whereas all samples with mostly maternal monocytes/macrophages or a mixture of both were from women who delivered term or late preterm neonates (100% [7/7]). (5) Most of the women included in this study presented acute maternal and fetal inflammatory responses in the placenta (85.7% [12/14]). (6) Women who had mostly fetal monocytes/macrophages in amniotic fluid had abundant CD14+ cells in the umbilical cord and chorionic plate, whereas women with mostly maternal amniotic fluid monocytes/macrophages had abundant CD14+ cells in the chorioamniotic membranes. Conclusion Amniotic fluid monocytes/macrophages can be of either fetal or maternal origin, or a mixture of both, in women with intra-amniotic inflammation or infection. These immune cells could be derived from the fetal and maternal vasculature of the placenta.

A randomised controlled trial of amnioexchange for fetal gastroschisis

OBJECTIVE

Morbidity in fetuses affected by gastroschisis is mainly the result of bowel ischaemic and inflammatory processes. Experimental studies on animal models show that clearing amniotic fluid from the digestive secretions by amnioexchange procedures reduces the inflammatory process. We evaluated the benefit of the amnioexchange procedure for fetal gastroschisis in humans.

DESIGN

Prospective, interventional, randomised study.

SETTING

Eight referral centres for fetal medicine.

POPULATION

Pregnant women carrying a fetus with gastroschisis.

METHODS

We compared, in utero, amnioexchange with a sham procedure. The protocol included, in both arms, steroid injections at 30 weeks of gestation and the use of postnatal minimal enteral feeding.

MAIN OUTCOME MEASURES

The primary outcome was a composite variable based on the duration of ventilation and parenteral nutrition. Secondary outcomes were the effectiveness and safety of the amnioexchange procedure, including the rate of perinatal death, time to full enteral feeding, primary closure, and late feeding disorders.

RESULTS

Sixty-four patients were randomised. There was no difference in the composite criteria between the amnioexchange and control groups. Based on an intention-to-treat analysis, there were no significant between-group differences in pregnancy outcome or complications. When studying the relationship between digestive compounds and amniotic fluid inflammatory markers, a clear correlation was found between bile acid and both ferritin and interleukin 1β (IL1β).

CONCLUSIONS

In humans, amnioexchange, as described in our protocol, is not an option for fetal care; however, we provide supplementary proof of the involvement of inflammation in the pathogenicity of gastroschisis and suggest that future research should aim at reducing inflammation. ClinicalTrials.gov: NCT00127946.

TWEETABLE ABSTRACT

A prospective, interventional, randomised study shows no benefit of amnioexchange for fetal gastroschisis in humans.

The immunophenotype of amniotic fluid leukocytes in normal and complicated pregnancies

PROBLEM

The immune cellular composition of amniotic fluid is poorly understood. Herein, we determined: 1) the immunophenotype of amniotic fluid immune cells during the second and third trimester in the absence of intra-amniotic infection/inflammation; 2) whether amniotic fluid T cells and ILCs display different phenotypical characteristics to that of peripheral cells; and 3) whether the amniotic fluid immune cells are altered in women with intra-amniotic infection/inflammation.

METHOD OF STUDY

Amniotic fluid samples (n = 57) were collected from 15 to 40 weeks of gestation in women without intra-amniotic infection/inflammation. Samples from women with intra-amniotic infection/inflammation were also included (n = 9). Peripheral blood mononuclear cells from healthy adults were used as controls (n = 3). Immunophenotyping was performed using flow cytometry.

RESULTS

In the absence of intra-amniotic infection/inflammation, the amniotic fluid contained several immune cell populations between 15 and 40 weeks. Among these immune cells: (i) T cells and ILCs were greater than B cells and natural killer (NK) cells between 15 and 30 weeks; (ii) T cells were most abundant between 15 and 30 weeks; (iii) ILCs were most abundant between 15 and 20 weeks; (iv) B cells were scarce between 15 and 20 weeks; yet, they increased and were constant after 20 weeks; (v) NK cells were greater between 15 and 30 weeks than at term; (vi) ILCs expressed high levels of RORγt, CD161, and CD103 (ie, group 3 ILCs); (vii) T cells expressed high levels of RORγt; (viii) neutrophils increased as gestation progressed; and (ix) monocytes/macrophages emerged after 20 weeks and remained constant until term. All of the amniotic fluid immune cells, except ILCs, were increased in the presence of intra-amniotic infection/inflammation.

CONCLUSION

The amniotic fluid harbors a diverse immune cellular composition during normal and complicated pregnancies.

Hypoxic renal injury in newborns with abdominal compartment syndrome (clinical and experimental study)

BackgroundSurgical treatment for gastroschisis and congenital diaphragmatic hernia (CDH) commonly leads to abdominal compartment syndrome (ACS) associated with hypoxic renal injury. We hypothesized that measurement of urinary and serum concentrations of vascular endothelial growth factor (VEGF), π-glutathione S-transferase (π-GST), and monocyte chemoattractant protein-1 (MCP-1) may serve for noninvasive detection of hypoxic renal injury in such patients.MethodsIntra-abdominal pressure (IAP), renal excretory function, and the biomarker levels were analyzed before, 4, and 10 days after surgery. Association between the biomarker levels and renal histology was investigated using an original model of ACS in newborn rats.ResultsFour days after surgery, IAP increased, renal excretory function decreased, and the levels of VEGF, π-GST, and MCP-1 increased, indicating renal injury. Ten days after surgery, IAP partially decreased, renal excretory function completely restored, but the biomarker levels remained elevated, suggesting the ongoing kidney injury. In the model of ACS, increase in the biomarker levels was associated with progressing kidney morphological alteration.ConclusionSurgical treatment for gastroschisis and CDH is associated with prolonged hypoxic kidney injury despite complete restoration of renal excretory function. Follow-up measurement of VEGF, π-GST, and MCP-1 levels may provide a better tool for noninvasive assessment of renal parenchyma in newborns with ACS.

The intestinal damage induced by lipid soluble meconium subfraction is profound compared to the intestinal damage induced by water soluble meconium subfraction

BACKGROUND

It is unclear which substances in meconium are responsible for intestinal damage in gastroschisis. An experimental study was designed to investigate the effects of the lipid or water soluble subfractions of meconium on the intestines of gastroschisis in a chick model.

METHODS

Meconium was pooled, homogenated, rota-evaporated dry and diluted. Meconium subfractions were obtained from water soluble and lipid soluble extracts of the meconium. Five days old fertilized chick embryos were used and divided into 5 groups: control, sham, water soluble meconium subfraction, lipid soluble meconium subfraction and whole meconium. All embryos were extirpated on the 18days and the intestines were harvested for histopathological examination. Serosal thickness was measured under light microscopy.

RESULTS

Serosal thickness of the meconium (36.36±2.8μm), the water soluble meconium (14.15±0.93μm) and the lipid soluble meconium (23.88±1.69μm) subfractions groups were significantly increased compared with the control (7.47±0.68μm) and the sham (7.48±0.71μm) groups (p<0.001). Serosal thickness of the lipid soluble meconium subfraction group was significantly increased compared with the water soluble meconium subfraction group (p<0.001). Serosal thickness of the meconium group was significantly increased compared to both the water and the lipid soluble meconium subfraction groups (p<0.001).

CONCLUSION

Lipid soluble meconium subfraction induces more intestinal damage compared to water soluble meconium subfraction.

Heightened Immune Activation in Fetuses with Gastroschisis May Be Blocked by Targeting IL-5

The development of the fetal immune system during pregnancy is a well-orchestrated process with important consequences for fetal and neonatal health, but prenatal factors that affect immune activation are poorly understood. We hypothesized that chronic fetal inflammation may lead to alterations in development of the fetal immune system. To test this hypothesis, we examined neonates with gastroschisis, a congenital abdominal wall defect that leads to exposure of the fetal intestines to amniotic fluid, with resultant intestinal inflammation. We determined that patients with gastroschisis show high systemic levels of inflammatory cytokines and chemokines such as eotaxin, as well as earlier activation of CD4(+) and CD8(+) effector and memory T cells in the cord blood compared with controls. Additionally, increased numbers of T cells and eosinophils infiltrate the serosa and mucosa of the inflamed intestines. Using a mouse model of gastroschisis, we observed higher numbers of eosinophils and both type 2 and type 3 innate lymphoid cells (ILC2 and ILC3), specifically in the portion of organs exposed to the amniotic fluid. Given the role of IL-5 produced by ILC2 in regulating eosinophil development and survival, we determined that maternal or fetal administration of the anti-IL-5 neutralizing Ab, or a depleting Ab against ILCs, can both effectively reduce intestinal eosinophilia. Thus, a congenital anomaly causing chronic inflammation can alter the composition of circulating and tissue-resident fetal immune cells. Given the high rate of prenatal and neonatal complications in these patients, such changes have clinical significance and might become targets for fetal therapy.

The long-term neurodevelopmental and psychological outcomes of gastroschisis: A cohort study

OBJECTIVES

Previous gastroschisis specific neurodevelopmental studies have focused on the first 3years of life. The aim of this study was to assess the intellectual, behavioral and neurological outcomes of older children and adolescents born with gastroschisis.

STUDY DESIGN

Of 99 gastroschisis survivors born in Western Australia, 1992 to 2005, and who were at least 5years old, 42 agreed to take part in this study. The study assessed: intellectual ability, with age appropriate Wechsler intelligence scales; neurological status; hearing; vision; behavioral status with the Strengths and Difficulties Questionnaire (SDQ); and parenting style with the Parenting Relationship Questionnaire (PRQ). All results were compared to normative means.

RESULTS

Median age at follow-up was 10years (range 5-17). No child had evidence of cerebral palsy or hearing loss; 1 child had amblyopia. Psychometric tests were completed in 39 children: mean full scale IQ was 98.2 (standard deviation [SD] 10.7); the working memory index was the only subscale to show a significant decrease from the normative mean (mean 95.5, SD 12.4, p=0.038). The mean SDQ behavioral scores were significantly lower for 3 of 5 domains and the Total Difficulties score. PRQ scores were significantly abnormal for 4 of 7 domains: Communication, Discipline, Satisfaction with School and Relational Frustration.

CONCLUSIONS

Overall intellectual abilities were within a normal range. The decrease in working memory index and the behavioral and parenting relationship impairments could be an effect of perinatal factors, gastroschisis management and complications or the complexity of the socio-economic environment.

Predicting Perinatal Outcome from Prenatal Ultrasound Characteristics in Pregnancies Complicated by Gastroschisis

Introduction: The objective of the study was to establish the predictive value of prenatal ultrasound markers for complex gastroschisis (GS) in the first 10 days of life. Material and Methods: In this retrospective cohort study over 11 years (2000-2011) of 117 GS cases, the following prenatal ultrasound signs were analyzed at the last second- and third-trimester ultrasounds: intrauterine growth restriction, intra-abdominal bowel dilatation (IABD) adjusted for gestational age, extra-abdominal bowel dilatation (EABD) ≥25 mm, stomach dilatation, stomach herniation, perturbed mesenteric circulation, absence of bowel lumen and echogenic dilated bowel loops (EDBL). Results: Among 114 live births, 16 newborns had complex GS (14.0%). Death was seen in 16 cases (13.7%): 3 intrauterine fetal deaths, 9 complex GS and 4 simple GS. Second-trimester markers had limited predictive value. Third-trimester IABD, EABD, EDBL, absence of intestinal lumen and perturbed mesenteric circulation were statistically associated with complex GS and death. IABD was able to predict complex GS with a sensitivity of 50%, a specificity of 91%, a positive predictive value of 47% and a negative predictive value of 92%. Discussion: Third-trimester IABD adjusted for gestational age appears to be the prenatal ultrasound marker most strongly associated with adverse outcome in GS.

Factors associated with gastroschisis outcomes

OBJECTIVE

To identify perinatal variables associated with adverse outcomes in neonates prenatally diagnosed with gastroschisis.

METHODS

A retrospective review was conducted of all inborn pregnancies complicated by gastroschisis within the five institutions of the University of California Fetal Consortium from 2007 to 2012. The primary outcome was a composite adverse neonatal outcome comprising death, reoperation, gastrostomy, and necrotizing enterocolitis. Variables collected included antenatal ultrasound findings, maternal smoking or drug use, gestational age at delivery, preterm labor, elective delivery, mode of delivery, and birth weight. Univariate and multivariate analysis was used to assess factors associated with adverse outcomes. We also evaluated the association of preterm delivery with neonatal outcomes such as total parenteral nutrition cholestasis and length of stay.

RESULTS

There were 191 neonates born with gastroschisis in University of California Fetal Consortium institutions at a mean gestational age of 36 3/7±1.8 weeks. Within the cohort, 27 (14%) had one or more major adverse outcomes, including three deaths (1.6%). Early gestational age at delivery was the only variable identified as a significant predictor of adverse outcomes on both univariate and multivariate analysis (odds ratio 1.4, 95% confidence interval 1.1-1.8 for each earlier week of gestation). Total parenteral nutrition cholestasis was significantly more common in neonates delivered at less than 37 weeks of gestation (38/115 [33%] compared with 11/76 [15%]; P<.001).

CONCLUSION

In this contemporary cohort, earlier gestational age at delivery is associated with adverse neonatal outcomes in neonates with gastroschisis. Other variables, such as antenatal ultrasound findings and mode of delivery, did not predict adverse neonatal outcomes.

Spontaneous onset of labor, not route of delivery, is associated with prolonged length of stay in babies with gastroschisis

BACKGROUND/PURPOSE

We studied obstetric delivery practices for fetal gastroschisis and correlated this with neonatal outcomes. Our objectives were to identify changes in delivery practices over time and to determine if these changes resulted in improved neonatal outcomes.

METHODS

After IRB approval, maternal and neonatal records from 219 gastroschisis births between 1990 and 2008 were reviewed. Obstetrical data and neonatal data were collected. Univariate comparisons were made between maternal delivery variables and neonatal outcomes. Significant and clinically relevant obstetrical variables were combined for multivariate linear regression modeling.

RESULTS

The practice of elective cesarean delivery (ELCS) shifted to spontaneous vaginal delivery (sVD) over time (p <0.001). Babies born by sVD had longer hospitalization than those born by ELCS (median 36.0 vs 21.6days, p <0.05). Gestational age (GA) and birth weight were similar between groups. Babies born by induced VD (iVD) had short hospitalization (median 22.5days). A linear regression model demonstrated that spontaneous onset of labor (SOL) and GA were independently related to LOS.

CONCLUSIONS

Over nearly two decades, delivery of gastroschisis babies shifted from ELCS to sVD, a practice associated with a significantly longer LOS. Regression models suggest that shorter LOS could be achieved if elective delivery modes are utilized prior to SOL.

Gastroschisis--what should be told to parents?

Gastroschisis is a common congenital abdominal wall defect. It is almost always diagnosed prenatally thanks to routine maternal serum screening and ultrasound screening programs. In the majority of cases, the condition is isolated (i.e. not associated with chromosomal or other anatomical anomalies). Prenatal diagnosis allows for planning the timing, mode and location of delivery. Controversies persist concerning the optimal antenatal monitoring strategy. Compelling evidence supports elective delivery at 37  weeks' gestation in a tertiary pediatric center. Cesarean section should be reserved for routine obstetrical indications. Prognosis of infants with gastroschisis is primarily determined by the degree of bowel injury, which is difficult to assess antenatally. Prenatal counseling usually addresses gastroschisis issues. However, parental concerns are mainly focused on long-term postnatal outcomes including gastrointestinal function and neurodevelopment. Although infants born with gastroschisis often endure a difficult neonatal course, they experience few long-term complications. This manuscript, which is structured around common parental questions and concerns, reviews the evidence pertaining to the antenatal, neonatal and long-term implications of a fetal gastroschisis diagnosis and is aimed at helping healthcare professionals counsel expecting parents.

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.

Expectant management compared with elective delivery at 37 weeks for gastroschisis

OBJECTIVE

To estimate obstetric and neonatal outcomes after induction of labor at 37 weeks of gestation compared with expectant management in pregnancies complicated by fetal gastroschisis.

METHODS

The management of 296 pregnancies involving fetal gastroschisis (1980-2011) was reviewed from a single perinatal center. Ultrasound surveillance and nonstress testing were performed every 2 weeks from 30 weeks of gestation, weekly from 34 weeks of gestation, and twice weekly after 35 weeks of gestation until delivery. Labor was induced if fetal well-being testing was abnormal and, since 1994, labor was routinely induced at 37 weeks of gestation.

RESULTS

Of 153 pregnancies reaching 37 weeks of gestation, labor was induced in 77 (26%) and 76 (25.7%) were allowed to labor spontaneously. There were no significant differences in mean maternal age (22 years in both), parity (56% compared with 66% nulliparous), presence of other fetal anomalies (12% compared with 9%), cesarean delivery rate (20% in both), 5-minute Apgar score less than 7 (10% compared with 12%), meconium at birth (36% compared with 49%), or respiratory distress syndrome (16% compared with 7%) between the induced and expectantly managed groups. However, neonatal sepsis (25% compared with 42%; P=.02) and a composite outcome of neonatal death and bowel damage (necrosis, atresia, perforation, adhesion; 8% compared with 21%; P=.02) were more common in expectantly managed pregnancies. Moreover, time to oral feeds (-3.4 days), time on total parenteral nutrition (-6.2 days), and hospital stay (-6.7 days) were reduced when labor was induced.

CONCLUSION

In fetuses with gastroschisis, induction of labor at 37 weeks of gestation was associated with reduced risks of sepsis, bowel damage, and neonatal death compared with pregnancies managed expectantly beyond 37 weeks of gestation.

LEVEL OF EVIDENCE

II.

Is preterm delivery indicated in fetuses with gastroschisis and antenatally detected bowel dilation?

INTRODUCTION

Due to the controversy surrounding diagnostic ultrasound evaluations and elective preterm delivery of fetuses with gastroschisis, we sought to calculate the predictive value of bowel dilation in fetuses with gastroschisis and evaluate the effect of preterm delivery on neonatal outcomes.

MATERIALS AND METHODS

Ultrasounds and medical records of 103 mother-infant pairs with fetal gastroschisis were reviewed. Eighty-nine pairs met the criteria. Intestinal complications, gestational age at delivery, birth weight, and number of abdominal surgeries were documented.

RESULTS

Forty-eight fetuses (54%) had bowel dilation and 41 (46%) did not. The positive predictive value of bowel dilation for complicated gastroschisis was 21%. There were 50 (56%) preterm and 39 (44%) term deliveries. The mean birth weight was 2,114 g (SD = 507) and 2,659 g (SD = 687), p = 0.001. For infants delivered preterm, the mean number of postnatal abdominal surgeries was 2.1 (SD = 1.1) as compared to 1.3 (SD = 0.5) surgical procedures for those infants delivered at term gestation. This was not statistically significant. With respect to hospital stay for each group, the mean length of neonatal intensive care unit admission was 48 days (SD = 33) in the preterm group and 35 days (SD = 50) in the term group, which was not statistically significant.

DISCUSSION

Ultrasound-detected bowel dilation was not predictive of important intestinal complications. Our data did not substantiate any benefit for elective preterm delivery of neonates with gastroschisis.

Effects of nonocclusive mesenteric hypertension on intestinal function: implications for gastroschisis-related intestinal dysfunction

INTRODUCTION

Infants with gastroschisis (GS) have significant morbidity from dysmotility, feeding intolerance, and are at increased risk of developing intestinal failure. Although the molecular mechanisms regulating GS-related intestinal dysfunction (GRID) are largely unknown, we hypothesized that mechanical constriction (nonocclusive mesenteric hypertension (NMH)) from the abdominal wall defect acts as a stimulus for GRID. The purpose of this study was to determine the effect of NMH on intestinal function and inflammation.

METHODS

Neonatal rats had placement of a silastic disk to the base of the mesentery (NMH) or no disk placement (Sham). At 24 and 72 h, mesenteric venous pressures (MVPs), intestinal transit, electric impedance, permeability, length, and tissue water content were measured.

RESULTS

After placement of the silastic disk, there was a significant increase in MVP at both time points. There was also decreased intestinal transit. As compared to Sham animals, NMH animals had significant changes in bowel impedance without an increase in tissue water, suggesting significant intestinal remodeling. NMH rats had significantly increased smooth-muscle thickness and loss of intestinal length as compared with Sham rats.

DISCUSSION

NMH may be an initiating factor for GRID. Measurement of MVP and/or bowel impedance may be a way to assess severity and monitor progression and/or resolution of GRID.

Neonatal abdominal wall defects

Gastroschisis and omphalocele are the two most common congenital abdominal wall defects. Both are frequently detected prenatally due to routine maternal serum screening and fetal ultrasound. Prenatal diagnosis may influence timing, mode and location of delivery. Prognosis for gastroschisis is primarily determined by the degree of bowel injury, whereas prognosis for omphalocele is related to the number and severity of associated anomalies. The surgical management of both conditions consists of closure of the abdominal wall defect, while minimizing the risk of injury to the abdominal viscera either through direct trauma or due to increased intra-abdominal pressure. Options include primary closure or a variety of staged approaches. Long-term outcome is favorable in most cases; however, significant associated anomalies (in the case of omphalocele) or intestinal dysfunction (in the case of gastroschisis) may result in morbidity and mortality.

Does gastric dilation predict adverse perinatal or surgical outcome in fetuses with gastroschisis?

OBJECTIVE

To compare perinatal and infant surgical outcomes in fetuses with gastroschisis with and without gastric dilation in a single-center cohort.

METHODS

This was a retrospective study of all singleton pregnancies with a prenatal diagnosis of gastroschisis managed at University of Toronto perinatal centers between January 2001 and February 2010. Digital prenatal ultrasound images were reviewed to determine fetal gastric size within 2 weeks of delivery. Perinatal and surgical outcomes were compared in fetuses with and without gastric dilation including: gestational age at delivery, mode of delivery, indication for Cesarean section, meconium-stained amniotic fluid, birth weight percentile, Apgar scores at 1 and 5 min, umbilical artery pH, time to full enteral feeding, length of hospital stay, bowel atresia or necrosis and need for bowel resection.

RESULTS

Ninety-eight fetuses with prenatally diagnosed gastroschisis managed at our center were included in the study, of which 32 (32.7%) were found to have gastric dilation. Gastric dilation predicted meconium-stained amniotic fluid at delivery (53% vs. 24%; P = 0.017), but no other adverse perinatal outcome. Surgical morbidity rates (bowel atresia, bowel necrosis, perforation diagnosed postnatally, need for bowel resection, total time to full enteral feeding and length of hospital stay) were unaffected by gastric dilation.

CONCLUSIONS

In gastroschisis, fetal gastric dilation is associated with meconium-stained amniotic fluid at delivery, but is not predictive of any serious perinatal or postnatal complications. Fetal growth and well-being should be serially evaluated on ultrasound using biophysical and Doppler assessment to decide on the optimal timing and mode of delivery.

The role of calprotectin in obstetrics and gynecology

The purpose of this article is to create the first complete review concerning the role of calprotectin, a calcium- and zinc-binding protein of the S100/calgranulins family, in obstetrics and gynecology. A Medline search was conducted between 6 and 8 June 2009 using the term calprotectin and its synonyms combined with the following ones: calprotectin, obstetrics and gynecology, breast cancer, ovarian cancer, endometrial cancer, cervical cancer, menstrual cycle, pregnancy, fetal implantation, labor, intra-amniotic inflammation, preeclampsia, HELLP syndrome, Rh(-) incompatibility. We found 46 studies which referred to obstetrics and gynecology. We excluded 11 studies which referred to obstetrics and gynecology but did not include enough information about calprotectin, and another two which referred to calprotectin but were not related to subjects of obstetrics and gynecology. Thus, we ended up with 33 studies which contained sufficient information to extract data for this review. All the articles were written in English. It was found that calprotectin is associated with many physiologic and pathologic processes in obstetrics and gynecology, such as: breast cancer, ovarian cancer, endometrial cancer, cervical cancer, cervical and vaginal physiology, menstrual cycle, pregnancy and labor. The role of calprotectin in these conditions is significant. In conclusion, the role of calprotectin seems to be important in several issues of obstetrics and gynecology. For example, calprotectin could be used as a diagnostic, prognostic or metastatic marker in several types of cancer, as a marker of inflammation and as a pharmaceutical target in many conditions. Further studies must be conducted to elucidate this role.

Inflammatory response in a rat model of gastroschisis is associated with an increase of NF-kappaB

Babies with gastroschisis have high morbidity, which is associated with inflammatory bowel injury caused by exposure to amniotic fluid. The objective of this study was to identify components of the inflammatory response in the intestine and liver in an experimental model of gastroschisis in rats. The model was surgically created at 18.5 days of gestation. The fetuses were exposed through a hysterotomy and an incision at the right of the umbilicus was made, exposing the fetal bowel. Then, the fetus was placed back into the uterus until term. The bowel in this model had macro- and microscopic characteristics similar to those observed in gastroschisis. The study was conducted on three groups of 20 fetuses each: gastroschisis, control, and sham fetuses. Fetal body, intestine and liver weights and intestine length were measured. IL-1beta, IL-6, IL-10, TNF-alpha, IFN-gamma and NF-kappaB levels were assessed by ELISA. Data were analyzed statistically by ANOVA followed by the Tukey post-test. Gastroschisis fetuses had a decreased intestine length (means +/- SD, 125 +/- 25 vs 216 +/- 13.9; P < 0.005) and increased intestine weight (0.29 +/- 0.05 vs 0.24 +/- 0.04; P < 0.005). Intestine length correlated with liver weight only in gastroschisis fetuses (Pearson's correlation coefficient, r = 0.518, P = 0.019). There were no significant differences in the concentrations of IL-1beta, TNF-alpha or IFN-gamma in the intestine, whereas the concentration of NF-kappaB was increased in both the intestine and liver of fetuses with gastroschisis. These results show that the inflammatory response in the liver and intestine of the rat model of gastroschisis is accompanied by an increase in the amount of NF-kappaB in the intestine and liver.

In utero repair of gastroschisis in the sheep (Ovis aries) model

OBJECTIVE

Gastroschisis is associated with inflammatory changes in the exposed bowel which leads to intestinal dysmotility after postnatal repair. The insult is a combined effect of amniotic fluid exposure and mechanical constriction. We hypothesized that in utero anatomic repair is possible in a sheep model, and that it may halt the inflammatory damage caused by both mechanisms.

METHODS

Gastroschisis was surgically created in mid-gestation (day 75) in 8 sheep fetuses. On gestational day 100, 2 fetuses underwent open fetal gastroschisis repair, where the eviscerated bowel was returned to the peritoneal cavity, and the abdominal wall was primarily closed. All fetuses were harvested at 135 days of gestation.

RESULTS

Six fetuses survived the initial operation, and both fetuses that underwent gastroschisis repair survived to term. At 100 and 135 days of gestation, the eviscerated bowel showed progressive signs of inflammation and peel development. The gross and microscopic inflammatory changes in the gastroschisis bowel at 100 days of gestation were completely resolved at term following in utero repair.

CONCLUSION

In utero anatomic repair of gastroschisis is possible in mid-gestation in the fetal lamb model, and it appears to ameliorate the inflammatory process.

Delivery of gastroschisis patients before 37 weeks of gestation is associated with increased morbidities

BACKGROUND

Despite advances in the care of neonates with gastroschisis, patients present with significant morbidities. Preterm delivery of neonates with gastroschisis is often advocated to avoid the intestinal damage that may be sustained with prolonged exposure to amniotic fluid. However, preterm delivery may impose additional morbidities to this disease process.

METHODS

We conducted a retrospective review of patients with gastroschisis born from 1989 to 2007. Demographic and clinical data were collected. Preterm healthy neonates, with gestational age from 26 to 36 weeks, were used as controls.

RESULTS

Preterm infants with gastroschisis had a 14 times higher risk for any of the recorded morbidities. As compared to term neonates with gastroschisis, preterm neonates with gastroschisis had a higher rate of sepsis, longer duration to reach full enteral feedings, and longer length of stay. Although the preterm infants with gastroschisis were less likely to be small for gestational age at birth, they were as likely as the term infants with gastroschisis to have failure to thrive at discharge and had a greater drop in weight percentile during hospitalization.

CONCLUSIONS

Preterm delivery should be avoided because there is no clear benefit to the gut in avoiding derivative injuries. Meticulous attention should be given to the nutritional needs of patients with gastroschisis.

Ward reduction of gastroschisis in a single stage without general anaesthesia may increase the risk of short-term morbidities: results of a retrospective audit

BACKGROUND

 Ward reduction of gastroschisis in a single stage without the need for general inhalational anaesthesia (ward reduction) has been reported by some authors to be effective and safe. We introduced this practice to our neonatal unit 2 years ago.

AIM

To compare the short-term outcomes of this new practice with the standard procedure of reduction under general anaesthesia (GA).

METHODS

Retrospective case series of all infants with gastroschisis between January 2004 and January 2008.

RESULTS

Twenty-seven infants were managed with the traditional approach and 11 infants underwent ward reduction without GA. Infants in the ward reduction group had an increased frequency for all the three major adverse events (ischemic necrosis of bowel: 27.3% vs. 3.7%, odds ratio (OR) 10.72, 95% confidence interval (CI): 0.72, 159.6; need for total parenteral nutrition (TPN) more than 60 days: 18% vs. 3.7%, OR 4.13, 95% CI: 0.28, 61.55; and unplanned return to theatre: 27.3% vs. 7.4%, OR 3.88, 95% CI: 0.44, 34.08), although none of these events reached statistical significance. There were no significant differences between the groups for the outcomes of time to reach full feeds, duration of hospital stay and number of days on antibiotics.

CONCLUSIONS

These results raise concerns over the role of ward reduction of gastroschisis in a single sitting without the use of GA. Randomised trials with appropriate design and sample size are needed before embracing this method as a standard practice.

Cadmium-induced enteropathy in domestic cocks: a biochemical and histological study after subchronic exposure

The biochemical and histological sequelae resulting from a diet containing 50.20 mg cadmium/kg were studied in Lohmann brown cockerels from hatching until 30 days of age. The additional cadmium chloride (CdCl(2)) to the diet induced the formation of lipid peroxides, which via a chain reaction led to accumulation of malondialdehyde in intestinal mucosa. At the end of the study (after 30 days of cadmium exposure) total protein and metallothionein levels in the intestinal mucosa and the relative ileal and duodenal weight increased. Histological data show that CdCl(2) causes an increase in number of goblet cells and granular lymphocytes in the intestinal mucosa. Down-regulation of the serotonin-positive cells in the cadmium-treated animals was observed. Growth retardation (by 27%) occurred in chicken fed the cadmium-enriched diet for 30 days. Cadmium accumulation in the intestine was markedly higher (154 times) in the cadmium-treated animals compared to the control group. Cadmium induced a decrease in zinc (but not copper) content in intestinal mucosa. We suggest that cadmium uptake triggers an inflammatory and secretory response in chicken small intestine.