Current Concepts ⅢⅢⅢⅢⅢⅢⅢⅢⅢⅢⅢⅢⅢⅢ The With Gastroschisis Managed by a Trial of Labor: Antepartum and Intrapartum Complications

Eyal Y. Anteby, MD is typically an isolated anomaly with normal karyotype and is gener- Kara Sternhell ally considered to be associated with a good postnatal outcome.1–3 Jeffrey M. Dicke, MD Gastroschisis occurs in approximately 1 to 2 in 10,000 births,4 and an apparent increase in incidence, especially in young women, has re- 5 OBJECTIVE: cently been reported. With widespread use of ultrasonography and To assess the rate of antepartum and intrapartum complications of fe- maternal serum ␣-fetoprotein screening, an increasing number of tuses with antenatally diagnosed gastroschisis managed in a center that with gastroschisis are antenatally diagnosed. Determining the advocates a trial of labor. optimal antenatal management in general and the mode of delivery in particular, are thus increasingly relevant. Although some studies STUDY DESIGN: indicate a better prognosis for fetuses undergoing cesarean section A retrospective review. The medical records of 49 fetuses (1988 to 1997) (CS), most reports do not demonstrate improved outcome following who were prenatally diagnosed with gastroschisis by a sonologist in the abdominal delivery. However, interpretation of these studies is difficult Ultrasound Genetic Unit, Department of and Gynecology at because the majority are biased by several factors, including different Washington University, were reviewed. rates of inborn versus outborn and of antenatally diagnosed versus postnatally diagnosed among the groups. Given the controversy re- RESULTS: garding the optimal mode of delivery, determining the rate of ante- and intrauterine growth restriction were diagnosed in 23% partum and intrapartum complications and the actual success of a and 49% of the , respectively. A total of 22 women underwent trial of labor may help the decision process of the patient and her induction of labor: nine for nonreassuring fetal testing, four for premature obstetrician. rupture of membranes, five for marked bowel dilatation, one for preeclamp- Several small studies have reported an increased incidence of sia, and three for other reasons. Cesarean section (CS) was performed in 16 of intrauterine growth restriction (IUGR), oligohydramnios, and meco- 43 (37%) of women. The indications for CS were fetal distress (9 of 16 wom- nium-stained in fetuses with gastroschisis.6 Data re- en), (2 of 16 women), breech presentation (3 of 16 wom- garding the success rate of a trial of labor are currently limited. Since en), and physician discretion (2 of 16 women). No significant differences in 1988, we have advocated a trial of labor for all patients with gastros- Apgar scores were observed between the fetuses. Fetuses who were delivered by chisis delivered in Barnes-Jewish Hospital in St. Louis. This policy CS for fetal distress were more likely to have undergone an induction of labor allowed us to follow a cohort of pregnant women who were diagnosed (91% versus 44%), and they were smaller than fetuses with no evidence of with gastroschisis and subsequently managed at our institution. The Ϯ Ϯ Ͻ fetal distress (2220 105 gm versus 2613 80 gm, p 0.05). aim of our study was to determine the rate of antenatal and intrapar- tum complications in patients with gastroschisis that undergo a trial CONCLUSION: of labor. The incidence of antepartum and intrapartum complications in fetuses with gastroschisis is high. The rate of CS can reach 37%. These data may aid clinicians in counseling patients with gastroschisis. PATIENTS AND METHODS All cases of gastroschisis diagnosed at the Ultrasound Genetic Unit at BACKGROUND Barnes-Jewish Hospital between January 1988 and October 1997 were reviewed. A total of 49 fetuses were identified from the ultrasound Gastroschisis is characterized by evisceration of fetal intestine database. Three patients elected to undergo termination of , through a relatively small paraumbilical abdominal wall defect. It and intrauterine fetal demise occurred in three cases. The remaining 43 patients were followed and subsequently delivered at Barnes-Jewish Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO. Hospital. These patients comprise the study population. Data were

Address correspondence and reprint requests to Eyal Y. Anteby, MD, Department of Obstet- collected retrospectively by chart review performed by the authors. The rics and Gynecology, Hadassah University Hospital, Mt. Scopus, Jerusalem, Israel. sources of data included the ultrasound database and the hospital

Journal of Perinatology (1999) 19(7) 521–524 © 1999 Stockton Press. All rights reserved. 0743–8346/99 $12 http://www.stockton-press.co.uk 521 Anteby et al. Complications During Labor After Gastroschisis Diagnosis

Table 1 Antenatal Characteristics of the Study Population Table 2 Patients Route of Delivery Characteristic No. % Route of delivery No.

Nonreassuring fetal testing 10/43 23 Vaginal delivery 27 (63%) Premature rupture of membranes 5/43 12 CS 16 (37%) Dilated bowel loops 6/43 14 Elective 5/16 (31%) Preeclampsia 1/43 2 Fetal distress 9/16 (56%) Other 3/43 8 Chorioamnionitis 2/16 (13%) Total 25/43 58

medical records. The study was approved by Washington University Table 3 Intrapartum Characteristics of the Study Population Institutional Review Board. Following initial diagnosis, sonography is usually repeated Characteristic No. % monthly through the second trimester and as necessary thereafter to Nonreassuring fetal heart rate tracing* 8/38 21 monitor fetal growth, bowel dilation, and amniotic fluid volume. Presence of meconium (2ϩ to 4ϩ) 28/38 74 Antepartum fetal assessment also includes fetal movement and non- Chorioamnionitis† 3/38 8 stress testing or challenge testing. The ultrasound records *Necessitating cesarean section. were reviewed for fetal biometry and amniotic fluid volume. Fetal †Chorioamnionitis was diagnosed clinically. weight was estimated using measurements of the head circumference, abdominal circumference, and femur length and was then plotted on normograms constructed using our population. IUGR was diagnosed when the resulting fetal weight was less than the 10th percentile. The To determine whether intrapartum factors affected the neonatal decision to perform CS was based on obstetrical considerations in all parameters, we analyzed these parameters in each of the four groups: but two cases in which physician discretion was the indication for elective CS, CS for fetal distress, CS for amnionitis and no progress, surgery. The hospital delivery records were analyzed for indication for and vaginal delivery. The results are shown in Table 4. CS for fetal delivery, results of antenatal testings, gestational age at delivery, pres- distress was associated with a significantly lower fetal weight but no ence of meconium, mode of delivery, indication for CS (if performed), difference in gestational age. No association was found between the birth weight, 1- and 5-minute Apgar scores, and umbilical artery pH. mode of delivery and Apgar scores or umbilical artery pH. For statistical analysis, we used Student’s t-test for comparison We subsequently determined whether antenatal factors were between groups and the ␹-squared analysis to analyze differences in associated with the development of fetal distress or chorioamnionitis categorical variables between the groups. p Ͻ 0.05 was considered and a subsequent need to undergo an emergency CS. Table 5 shows statistically significant. the results of this analysis. Induction of labor was associated with a higher risk of CS for fetal distress or amnionitis. The rate of oligohy- RESULTS dramnios and IUGR were higher among patients undergoing CS for fetal distress, but the difference did not reach statistical significance. The mean ϩ SD maternal age was 20.3 ϩ 5.8 years. Of the patients in this study, 29 of 43 (67%) were primigravidas. Antenatal ultra- sound evaluation revealed oligohydramnios in 10 of 43 (23%) pa- DISCUSSION tients. IUGR was antenatally diagnosed in 21 of 43 (49%) patients and was confirmed after delivery in 13 of 43 (30%) patients. Early Our study demonstrates that the rate of CS for fetuses with gastroschi- delivery by a trial of labor or by CS was advocated for 25 of 43 (58%) sis, in a center that advocates a trial of labor, can reach 37%. Fetal patients. The indications for induction of labor or early CS are pre- distress was the major indication for CS, accounting for CS in 21% of sented in Table 1. Gestational age at delivery was 36.7 Ϯ 1.8 patients undergoing a trial of labor. Breech presentation was the (mean Ϯ SD); mean birth weight was 2552 gm Ϯ 499 gm. indication for CS in 7% of the study population, with patient prefer- The mode of delivery is shown in Table 2. A total of 16 patients ence or chorioamnionitis each accounting for CS in 4.5% of patients. were delivered by CS (37%). Five patients did not undergo a trial of Previous reports of CS rates in fetuses with gastroschisis support labor: three for a breech presentation and two for physician discretion. our findings. Cheschier et al.7 reported a CS rate of 6 of 10 patients Nine patients were delivered by CS for fetal distress and two for chorio- undergoing a trial of labor. Indications for CS were markedly dilated amnionitis and slow progress of labor. A total of 38 patients under- bowel or a large amount of exteriorized bowel in four of six patients went a trial of labor. The intrapartum characteristics of these patients and breech presentation and fetal distress in one patient each. Craw- are presented in Table 3. ford et al.6 reported that 6 of 12 women who went into spontaneous

522 Journal of Perinatology (1999) 19(7) 521–524 Complications During Labor After Gastroschisis Diagnosis Anteby et al.

Table 4 Neonatal Parameters of Newborns that were Born by an Elective CS, CS for Fetal Distress, CS for Chorioamnionitis, and by Vaginal Delivery (mean Ϯ SE)

Elective CS (5) CS for fetal CS for Vaginal delivery distress (9) chorioamnionitis (2) (27)

Gestational age 36.6 (1.02) 36.0 (0.67) 39.6 (0.7) 36.8 (0.30) Weight 2515 (285) 2220 (105)* 3409 (619) 2613 (80)* Apgar 1 minute 6.8 (1.2) 5.7 (0.92) 8.0 (0) 6.6 (0.36) 5 minute 8.6 (0.24) 7.1 (0.63) 9.0 (0) 8.1 (0.33) pH 7.33 (0.026) 7.27 (0.06) 7.31 (0) 7.32 (0.026)

*p Ͻ 0.05.

6 Table 5 Antenatal Factors and the Development of Fetal Distress With delivery in 23% to 33% of patients. Crawford et al. reported that its a Need to Perform an Urgent CS rate after delivery may reach 67%. The mechanism for growth restric- tion in these fetuses is debatable. Transmural and transperitoneal loss CS for fetal Vaginal distress or delivery of proteins from the intestine to the amniotic fluid is one plausible chorioamnionitis explanation. This possibility is supported by the finding of hypogam- maglobulinemia, hypoalbuminemia, and low transferrin levels in Oligohydramnios 4/11 (36%) 5/27 (19%) fetuses with gastroschisis.11 IUGR 7/11 (64%) 12/27 (44%) Induction of labor 10/11 (91%)* 12/27 (44%)* Oligohydramnios was diagnosed in 23% of patients with gastros- Meconium 7/11 (64%) 18/27 (67%) chisis. The incidence of oligohydramnios in fetuses with gastroschisis has been shown previously to be 33% to 38%.6,8,10 A total of 74% of our Ͻ *p 0.05. patients had meconium-stained amniotic fluid. Crawford et al.6 and Adair et al.7 reported rates of 46% and 79%, respectively. The increased incidence of meconium staining may be associated with the higher labor were delivered by CS. Fetal distress was the indication in four rate of IUGR and fetal distress or, as suggested by Ingamells et al.,9 women and breech presentation in two. Adair et al.8 reported a rate of may result from bile vomiting by the fetus. CS in their population of 31% (9 of 29 patients). The indications were: A total of 58% of the patients underwent induction of labor, with fetal distress (five patients), physician preference (three patients), and the majority of the inductions being performed for nonreassuring breech presentation (one patient). Recently, Ingamells et al.9 reported fetal parameters. Induction rates of 19% to 40% have been reported a 37% rate of CS, with 19 of 20 CS being done for fetal distress. Pa- previously.6,9 These findings support the recommendation by Craw- tients who underwent a CS for fetal distress had a higher rate of in- ford et al.6 to initiate serial fetal biophysical assessments in these duction of labor and their infants had a lower birth weight compared complicated pregnancies. with women that underwent vaginal delivery. Fries et al.10 and Craw- We conclude that patients with gastroschisis undergoing a trial of ford et al.6 showed that fetuses with lower birth weights had a trend labor have a significant risk of CS. This risk is mainly due to in- toward an increased rate of CS. In an attempt to analyze the charac- creased rates of fetal distress and abnormal fetal presentation. The risk teristics of fetal distress in fetuses with gastroschisis, Ingamells et al.9 of fetal distress is associated with fetal growth restriction. These results analyzed the computerized findings in 18 fetuses may be helpful for patients with gastroschisis that consider a trial of with gastroschisis. In seven cases, the cardiotocography was classified labor. as highly abnormal, mainly because of reduced long- and short-term 6 variations. These were attributed to hypoxemia. Crawford et al. re- References ported baseline as the typical abnormality in the fetal 1. Stringer MD, Brereton RJ, Wright VM. Controversies in the management of gas- heart rate. The observation of an increased incidence of fetal distress troschisis: a study of 40 patients. Arch Dis Child 1991;66:34–6. is indirectly supported by the high rate of unexplained intrauterine 2. Muraji T, Tsugawa C, Nishijima E, et al. Gastroschisis: a 17-year experience. deaths and in fetuses with gastroschisis.6,8 J Pediatr Surg 1989;24:343–5. Growth restriction is a common finding in fetuses with gastros- chisis.2,3 We antenatally diagnosed IUGR in 50% of patients and con- 3. DiLorenzo M, Yazbeck S, Ducharme J. Gastroschisis: a 15-year experience. J Pedi- firmed its presence after delivery in 30% of patients. These findings are atr Surg 1987;22:710–2. comparable with those reported by Fries and Raynor, who antenatally 4. Goldbaum G, Daling J, Milham S. Risk factors for gastroschisis. Teratology 1990; diagnosed IUGR in 43% to 48% of patients and confirmed it after 42:397–403.

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5. Torfs C, Curry C, Roeper P. Gastroschisis. J Pediatr 1990;116:1–6. partum surveillance in the management of gastroschisis. Int J Gynecol Obstet 1996;52:141–4. 6. Crawford RAF, Ryan G, Wright VM, Rodeck CH. The importance of serial bio- physical assessment of fetal wellbeing in gastroschisis. Br J Obstet Gynaecol 1992; 9. Ingamells S, Saunders NJ, Burge D. Gastroschisis and reduced fetal heart-rate 99:899–902. variability. Lancet 1995;345:1024–5. 10. Fries MH, Filly RA, Callen PW, et al. Growth retardation in prenatally diagnosed 7. Chescheir NC, Azizkhan RG, Seeds JW, Lacey SR, Watson WJ. Counseling and care for cases of gastroschisis. J Ultrasound Med 1993;12:583–8. the pregnancy complicated by gastroschisis. Am J Perinatol 1991;8:323–9. 11. Mabogunje OA, Mahour GH. Omphalocele and gastroschisis: trends in survival 8. Adair CD, Rosnes J, Frge AH, Burrus DR, Nelson LH, Veille JC. The role of ante- across two decades. Am J Surg 1984;148:679–86.

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