In gastroschisis and ruptured omphalocele, the main concern is to avoid undue trauma to the exposed intestines during pregnancy and at the time of delivery. Possible therapeutic interventions include the alteration of timing, mode, and place of delivery.5 The debate over place of delivery has been for the most part resolved. The consensus favors delivery of infants with known abdominal defects at or close to a regional perinatal center with immediate access to neonatal intensive care and pediatric surgery capabilities.8 The potential benefits of cesarean delivery have been suggested by some9,10 but disputed by others.11 To date, no conclusive randomized study has established the superiority of one mode of delivery over the other, and most centers consider cesarean delivery in gastroschisis for obstetric reasons only.12
The cause of intestinal damage to some but not all infants with gastroschisis continues to be debated. Some suggest that damage to the intestine is due to a tight fascial ring leading to mesenteric venous congestion or ischemia.12 Although this has been studied experimentally in fetal lambs,3,13 rabbits,4,14 and chicks,15 conclusive evidence has yet to be offered that size of the defect affects outcome of gastroschisis in humans. This may be hampered, in part, by the difficulty in assessing and reliably quantifying the defect on serial ultrasound examinations, as was our experience. Others believe that the damage to the intestinal wall in many of these patients is due to prolonged exposure to the amniotic fluid, and have recommended early delivery1 or even, in selected cases, serial amnioinfusion to dilute the caustic effect of amniotic fluid.16,17 The findings of recent studies on the caustic effect of amniotic fluid2,18,19 have revived the previously held notion that premature delivery of infants with gastroschisis (as soon as pulmonary maturity can be established, between 35 and 37 weeks20) helps minimize intestinal damage.
The difficulty in interpreting many reports on outcome of infants with gastroschisis relates to the heterogeneity of the study populations. Most large cohorts mix inborn patients (in whom the diagnosis is often known antenatally) with patients born in peripheral institutions, and in whom the diagnosis was not known.20 The present cohort is unique in that all but three patients had been diagnosed antenatally and all but one delivered at a tertiary care institution. All but two of these mothers had been counseled by a pediatric surgeon and a neonatologist (two infants were born before the parents had a chance to meet the pediatric specialists). Prenatal diagnosis allowed us to closely monitor the pregnancy (ultrasonography every 2 weeks until the third trimester, and weekly thereafter). Although we acknowledge the use of certain ultrasonographic criteria, such as bowel diameter and bowel wall thickness,3 we have not found these to be useful. In our cohort there were no instances of early delivery dictated by worsening ultrasonographic signs. The fact that, since 1991, we have stopped recommending routine cesarean and/or early delivery for gastroschisis has allowed us to critically evaluate the alleged benefits of preterm delivery. A cohort of 57 patients was divided into three groups, based on gestational age at delivery. (Whereas the numbers of infants born at 35–37 weeks and at more than 37 weeks are similar, there were only 11 patients in the less than 35 weeks group, possibly reducing the power of the analysis for that group.)
In our study, infants born at 35–37 weeks were less likely to undergo primary closure of the abdominal wall defect than infants born at term. If a silo was required, definitive closure was likely to occur later at 35–37 weeks than at more than 37 weeks or less than 35 weeks. Whereas in the latter two groups definitive closure could be achieved by 1.5–2.5 days, infants born between 35 and 37 weeks had closure, on average, at the end of the 1st week of life.
Age at first feedings and age at which a full enteral diet was tolerated were also greater at 35–37 weeks than at more than 37 weeks or less than 35 weeks. Very premature babies (less than 35 weeks) required more time to tolerate full feedings (42 days, versus 21 days in term babies), but even they tended to advance to full feedings more rapidly than infants born between 35 and 37 weeks (50 days). Length of stay was longer for premature infants than for those born at term, but delivery between 35 and 37 weeks did not result in earlier discharge than even the more preterm infants. In a recent study,21 length of hospitalization for infants with gastroschisis was correlated with gestational age. Although inverse linear correlation existed, a scattergram of that patient population suggested an increased length of stay between 35 and 37 weeks' gestation, much like the present study. Others have also found near-term delivery to be detrimental to feeding and length of hospitalization, although their cohorts were not homogeneous and invited a possible bias due to postnatal transport in some patients.20
Although the presence of an inflammatory peel was not quantified, owing to the somewhat subjective nature of this finding, actual bowel damage was not seen with greater frequency in more mature infants. Intestinal atresia, which is associated with gastroschisis in 10–15%, was seen in three infants, none full term. Fetal midgut volvulus, resulting in severe short bowel syndrome at birth (and leading to death in infancy) was seen twice, in premature infants. None of the live-born infants presented with major extraintestinal anomalies. In summary, prolonging gestation to term in these infants was not associated with a higher incidence of complications or associated defects.
We conclude that early delivery (before 37 weeks) offers no advantage in terms of primary closure of the abdominal wall defect, time to full bowel function, or length of hospitalization, and may in fact delay these milestones. Because duration of exposure of the exteriorized viscera to amniotic fluid does not correlate with bowel damage, we find it difficult to justify antenatal interventions such as early induction of labor or serial amnioinfusion to dilute amniotic fluid.
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