The timing of delivery of infants with gastroschisis influences outcome

Background

The delayed onset of intestinal function in children with gastroschisis may be because of the injurious effects of amniotic fluid on the exposed bowel. This has led to consideration of early delivery to minimize intestinal damage and improve outcome, although this has not been carefully evaluated. The authors hypothesized that timing of delivery influences outcome in children with gastroschisis, and sought to evaluate the relative impact of factors that predict outcome in this disease.

Methods

All consecutive patients with gastroschisis (1992-2002) were divided into those delivered before (“early”) or after (“late”) 36 weeks. Bowel peel was described as “thin” or “thick,” based on operative reports. Individual measures were analyzed by univariate analyses (χ²/Student's t test), and logistic regression was used to identify significant factors for the length of stay (LOS) longer than the population average of 55 days.

Results

In 75 patients, 53.4% were “early” and 46.6% were “late.” Groups were similar with respect to maternal age, birth weight, delivery mode, sex, and associated anomalies. Thickness of bowel peel was not affected by delivery time, yet “early” patients had significantly longer LOS and time to enteral feeds. Significant predictors of LOS more than 55 days included gestational age of 36 weeks or younger, time to enteral feeds of more than 26 days, and associated anomalies. Nonsignificant predictors included size of the defect, thickness of bowel peel, and need for silo.

Conclusions

Delivery before 36 weeks is associated with longer hospitalization and increased tune to attainment of full feeds compared with later delivery. Fetal well-being should thus be the primary determinant of delivery for gastroschisis, as opposed to considerations regarding possible injurious effects to the bowel of prolonged gestation.     

Effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes

Background/Purpose

This study examined the effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes, with adjustment for key confounding variables.

Methods

This retrospective cohort study included all gastroschisis patients treated at a single tertiary children's hospital between 1999 and 2009. Prenatal care, delivery mode (vaginal vs cesarean section before labor vs after labor), patient characteristics, and clinical outcomes were determined by chart review. Time to discontinuation of parenteral nutrition (PN) was the primary outcome of interest. Effects of multidisciplinary prenatal care and delivery mode were evaluated using Cox proportional hazards regression models that included gestational age, birth weight, sex, concomitant intestinal complications, and year of admission.

Results

Of 167 patients included, 46% were delivered vaginally, 69% received multidisciplinary prenatal care, and median time to PN discontinuation was 38 days. On multivariable modeling, gestational age, uncomplicated gastroschisis, and year of admission were significant predictors of early PN independence. Delivery mode and prenatal care had no independent effect on outcomes, although patients receiving multidisciplinary prenatal care were more likely to be born at term (49% vs 27%, P = .01).

Conclusions

Gestational age and intestinal complications are the major determinants of outcome in gastroschisis. Multidisciplinary prenatal care may facilitate term delivery.     

Routine cesarean delivery does not improve the outcome of infants with gastroschisis

Background/Purpose

The optimal mode of delivery for infants with gastroschisis is controversial. The authors compared the outcomes of infants with gastroschisis born vaginally (VD) or by cesarean section (CS).

Methods

A retrospective analysis of infants with gastroschisis born between 1990 and 2000 was performed. Assessment included patient demographics, respiratory distress, method of closure, number of surgeries, presence of atresia, feeding parameters, parenteral nutrition days (TPN), time to full feeding (FPO), mortality, and length of stay (LOS). Subgroup analyses were performed for those infants requiring cesarean section for fetal distress. Student’s t test/analysis of variance (ANOVA) or χ²/Fisher’s Exact tests were used for statistical analysis. Logistic and linear regression analyses were also performed.

Results

One hundred thirteen patients were studied (82 VD and 31 CS). No statistical difference existed between the VD and CS groups for perinatal complications, method of closure, number of surgeries (1.6 each), TPN (40.6 v 46.0 days), FPO (40.4 v 47.1 days), mortality (9.7 v 6.5%) and LOS (53.4 v 61.7 days). CS was associated with increased stenosis (25.8 v 4.9%; P = .003), gastrointestinal dysfunction (25.8 v 11.0%; P = .049), and respiratory distress (16.1 v 3.7%; P = .035). Many of these differences did not persist when infants undergoing CS for fetal distress were excluded from the analysis. However, regression analysis identified CS as an independent risk factor for the development of respiratory distress at birth (odds ratio, 7.11; CI, 1.06 to 47.7), with a trend to increased gastrointestinal dysfunction (odds ratio, 4.35; CI, 0.77 to 24.61).

Conclusions

The routine use of CS for infants with gastroschisis is not supported by our results because equivalent outcomes were observed with both modes of delivery. CS may be a necessary intervention for fetal distress.     

Relationship between age of pregnant women with gestational diabetes mellitus and mode of delivery and neonatal Apgar score

BACKGROUNDGestational diabetes mellitus (GDM) refers to abnormal glucose tolerance during pregnancy, and it is often accompanied by obvious changes in glucose and lipid metabolism, and associated with adverse pregnancy outcomes. The incidence of fetal distress, polyhydramnios, puerperal infection, premature delivery, and macrosomia in pregnant women with GDM are higher than in those without GDM.AIMTo analyze the relationship between age of pregnant women with GDM and mode of delivery and neonatal Apgar score.METHODSA total of 583 pregnant women with GDM who delivered in the Department of Obstetrics at our hospital between March 2019 and March 2022 were selected. Among them, 377 aged < 35 years were selected as the right age group and 206 aged > 35 years were selected as the older group. The clinical data of the two groups were collected, and the relationship between age of the pregnant women with GDM and mode of delivery, maternal and neonatal outcomes, and neonatal Apgar score were compared. In the older group, 159 women were classed as the adverse outcome group and 47 as the good outcome group according to whether they had adverse maternal and infant outcomes. The related factors of adverse maternal and infant outcomes were analyzed through logistic regression.RESULTSThe number of women with assisted pregnancy, ≤ 37 wk gestation, ≥ 2 pregnancies, one or more deliveries, and no pre-pregnancy blood glucose screening in the older group were all higher than those in the right age group (P < 0.05). The natural delivery rate in the right age group was 40.85%, which was higher than 22.33% in the older group (P < 0.05). The cesarean section rate in the older group was 77.67%, which was higher than 59.15% in the right age group (P < 0.05). The older group had a higher incidence of polyhydramnios and postpartum hemorrhage, and lower incidence of fetal distress than the right age group had (P < 0.05). There was no significant difference in neonatal weight between the two groups (P > 0.05). The right age group had higher Apgar scores at 1 and 5 min than the older group had (P < 0.05). Significant differences existed between the poor and good outcome groups in age, education level, pregnancy mode, ≤ 37 wk gestation, number of pregnancies, and premature rupture of membranes (P < 0.05). Logistic regression showed that age, education level and premature rupture of membranes were all risk factors affecting the adverse outcomes of mothers and infants (P < 0.05).CONCLUSIONDelivery mode and Apgar score of pregnant women with GDM are related to age. Older age increases the adverse outcome of mothers and infants.     

Early elective cesarean delivery before 36 weeks vs late spontaneous delivery in infants with gastroschisis

Purpose

The aim of this study is to assess the value of early elective cesarean delivery for patients with gastroschisis in comparison with late spontaneous delivery.

Methods

Analysis of infants with gastroschisis admitted between 1986 and 2006 at a tertiary care center was performed. The findings were analyzed statistically.

Results

Eighty-six patients were involved in the study. This included 15 patients who underwent emergency cesarean delivery (EM CD group) because of fetal distress and/or bowel ischemia. The remaining 71 patients born electively were stratified into 4 groups. The early elective cesarean delivery (ECD) group included 23 patients born by ECD before 36 weeks; late vaginal delivery (LVD) group included 23 patients who had LVD after 36 weeks; 24 patients had LCD after 36 weeks because of delayed diagnosis that resulted in late referral; and 1 patient had early spontaneous vaginal delivery (EVD group) before 36 weeks. The mean time to start oral feeding, incidence of complications, and primary closure were significantly better in the ECD group than in the LVD group. The duration of ventilation and the length of stay were shorter in ECD group, but the difference was not statistically significant.

Conclusion

Elective cesarean delivery before 36 weeks allows earlier enteral feeding and is associated with less complications and higher incidence of primary closure (statistically significant).     

Postnatal outcome in gastroschisis: effect of birth weight and gestational age

Introduction

Early elective delivery of antenatally diagnosed gastroschisis has been proposed as a strategy to minimize postnatal morbidity. This hypothesis was tested by analyzing outcome in relationship to gestational age and birth weight at delivery.

Methods

Single-center retrospective review of infants born with gastroschisis over a 13-year period (January 1993-December 2005). Standard outcome measures were compared using nonparametric methods. Data are quoted as median values (range).

Results

The study population consisted of 110 infants with gastroschisis. They were divided according to gestational age (group A, <35 weeks; group B, 35-37 weeks; group C, >37 weeks) and birth weight (group D, <2 kg; group E, 2-2.5 kg; group F, >2.5 kg).Duration in hospital (P < .01) and time to full enteral feeding (P = .05) was increased in group A vs groups B and C. In comparison, duration in hospital (P < .01), days ventilated (P = .03), establishment of full feeds (P = .01), and parentral nutrition (P = .02) were all prolonged in group D vs groups E and F.Six (5%) infants died (group D, n = 3; group E, n = 3). Necrotizing enterocolitis was found in 7 infants, and confined to groups D and E (χ² for trend P = .06).

Conclusion

There is no evidence that prematurity confers an advantage in restitution of gastrointestinal function in infants with gastroschisis; indeed, the opposite appears true. Birth weight, rather than gestational age, appears a better predictor of outcome.     

Mode of delivery and neonatal survival of infants with gastroschisis in Australia and New Zealand

Objective

The aim of the study was to examine the short-term outcome of infants with gastroschisis by route of delivery, comparing vaginal delivery vs elective and emergency cesarean delivery (CD).

Methods

Six hundred thirty-one infants with gastroschisis (International Classification of Diseases, 10th Revision: Q79.3) were admitted to the Australian and New Zealand Neonatal Network during 1997 to 2005. Multivariate Cox proportional hazards regression analysis was performed to adjust for case-mix and significant baseline characteristics.

Results

During the study period, 631 infants with gastroschisis were admitted to the collaborating centers. Of these, 343 (54.4%) infants were delivered vaginally, whereas 288 (45.6%) were delivered by cesarean birth. Of the latter, 148 (23.4%) were elective and 140 (22.2%) were emergency. There was an increasing trend of CD from 41.1% in 1997 to 69.0% in 2005.Forty-seven (7.4%) infants died; 30 (8.7%) in the vaginal, 9 (6.4%) in the emergency, and 8 (5.4%) in the elective CD group. There was no difference in rate of proven infection, duration of ventilation, or length of neonatal intensive care unit stay between the 3 groups.After controlling for prematurity, low birth weight, and outborn birth, the risk for neonatal demise was similar in both the vaginal and CD infants (adjusted hazard ratio, 1.486; 95% confidence interval, 0.814-2.713; P = .197). Stratifying the CD (emergency vs elective) gave similar results.

Conclusion

Infants with gastroschisis appear to be safely delivered vaginally.     

The impact of ibuprofen on renal clearance in preterm infants is independent of the gestational age

The aim of this investigation was to evaluate whether the relative change in renal clearance due to ibuprofen administration depends on the gestational age (GA). Clearance of amikacin was used as a surrogate marker for renal clearance in preterm infants (GA 24–34 weeks, day 1) on respiratory support. Clearance in infants co-treated with ibuprofen was compared to that of infants not co-treated with ibuprofen. Absolute change of clearance in four consecutive cohorts of increasing (<27, 27–28, 29–31, 32–34 weeks) GA and linear correlations of clearance on GA were calculated in both groups. Data were collected from 204 infants, of whom 93 were co-treated with ibuprofen. Mean amikacin clearance was lower (0.48 to 0.59 ml/kg/min, P <0.001) in infants co-treated with ibuprofen. Absolute decrease in mean amikacin clearance (0.10 to 0.14 ml/kg/min) was similar in all four cohorts. Linear correlations of clearance with GA were documented in infants co-treated (y =0.21+0.011x) or not co-treated (y =0.44+0.009x) with ibuprofen. Renal clearance, reflected by amikacin clearance, is decreased by ibuprofen in preterm infants of 24 to 34 weeks GA on respiratory support on the 1st day of life, independent of the GA. This work was presented at the meeting of the Dutch Society for Clinical Pharmacology and Biopharmacy, Lunteren, October 2004.     

Survival of very-low-birth-weight infants according to birth weight and gestational age in a public hospital.

OBJECTIVES: To determine the survival rates for infants weighing 500 - 1 499 g according to birth weight (BW) and gestational age (GA). DESIGN: This was a retrospective cohort study. Pregnancy and delivery data were collected soon after birth and neonatal data at discharge or at death. SETTING: Chris Hani Baragwanath Hospital (CHBH), a public-sector referral hospital, affiliated to the University of the Witwatersrand. SUBJECTS: Live births weighing between 500 g and 1 499 g delivered at or admitted to CHBH from January 2000 to December 2002. OUTCOME MEASURES: BW and GA-specific survival rates for all live infants born at CHBH and for those admitted for neonatal care. RESULTS: Seventy-two per cent of infants survived until discharge. The survival to discharge rate was 32% for infants weighing < 1 000 g, and 84% for those weighing 1 000 - 1 499 g. Survival rates at 26, 27 and 28 weeks' gestation were 38%, 50% and 65% respectively. Survival rates for infants admitted to the neonatal unit were better than rates for all live births, especially among those weighing < 1 000 g or with a GA < 28 weeks. There was a marked increase in survival between the 900 - 999 g and 1 000 - 1 099 g weight groups. Provision of antenatal care, caesarean section, female gender and an Apgar score more than 5 at 1 or 5 minutes were associated with better survival to hospital discharge. CONCLUSION: Survival among infants weighing less than 1 000 g is poor. In addition to severe prematurity, the poor survival among these infants (< 1 000 g) is most likely related to the fact that they were not offered mechanical ventilation. Mechanical ventilation should be offered to infants weighing < 1 000 g as it may improve their survival even in institutions with limited resources.     

The influence of age on propofol pharmacodynamics.

BACKGROUND: The authors studied the influence of age on the pharmacodynamics of propofol, including characterization of the relation between plasma concentration and the time course of drug effect. METHODS: The authors evaluated healthy volunteers aged 25-81 yr. A bolus dose (2 mg/kg or 1 mg/kg in persons older than 65 yr) and an infusion (25, 50, 100, or 200 microg x kg(-1) x min(-1)) of the older or the new (containing EDTA) formulation of propofol were given on each of two different study days. The propofol concentration was determined in frequent arterial samples. The electroencephalogram (EEG) was used to measure drug effect. A statistical technique called semilinear canonical correlation was used to select components of the EEG power spectrum that correlated optimally with the effect-site concentration. The effect-site concentration was related to drug effect with a biphasic pharmacodynamic model. The plasma effect-site equilibration rate constant was estimated parametrically. Estimates of this rate constant were validated by comparing the predicted time of peak effect with the time of peak EEG effect. The probability of being asleep, as a function of age, was determined from steady state concentrations after 60 min of propofol infusion. RESULTS: Twenty-four volunteers completed the study. Three parameters of the biphasic pharmacodynamic model were correlated linearly with age. The plasma effect-site equilibration rate constant was 0.456 min(-1). The predicted time to peak effect after bolus injection ranging was 1.7 min. The time to peak effect assessed visually was 1.6 min (range, 1-2.4 min). The steady state observations showed increasing sensitivity to propofol in elderly patients, with C50 values for loss of consciousness of 2.35, 1.8, and 1.25 microg/ml in volunteers who were 25, 50, and 75 yr old, respectively. CONCLUSIONS: Semilinear canonical correlation defined a new measure of propofol effect on the EEG, the canonical univariate parameter for propofol. Using this parameter, propofol plasma effect-site equilibration is faster than previously reported. This fast onset was confirmed by inspection of the EEG data. Elderly patients are more sensitive to the hypnotic and EEG effects of propofol than are younger persons.     

The impact of gestational age and fetal weight on the risk of failure of spinal anesthesia for cesarean delivery

BackgroundThere are limited data about spinal dosing for cesarean delivery in preterm parturients. We investigated the hypothesis that preterm gestation is associated with an increased incidence of inadequate spinal anesthesia for cesarean delivery compared with term gestation.MethodsWe searched our perioperative database for women who underwent cesarean delivery under spinal or combined spinal-epidural anesthesia with hyperbaric bupivacaine ⩾10.5 mg. The primary outcome was the incidence of inadequate surgical anesthesia needing conversion to general anesthesia or repetition or supplementation of the block. We divided patients into four categories: <28, 28 to <32, 32 to <37 and ⩾37 weeks of gestation. The chi-square test was used to compare failure rates and a multivariable regression analysis was performed to investigate potential confounders of the relationship between gestational age and failure.ResultsA total of 5015 patients (3387 term and 1628 preterm) were included. There were 278 failures (5.5%). The incidence of failure was higher in preterm versus term patients (6.4% vs. 5.1%, P=0.02). Failure rates were 10.8%, 7.7%, 5.3% and 5% for <28, 28 to <32, 32 to <37 and ⩾37 weeks of gestation, respectively. In the multivariable model, low birth weight (P<0.0001), gestational age (P=0.03), ethnicity (P=0.02) and use of combined spinal-epidural anesthesia (P<0.0001) were significantly associated with failure.ConclusionsAt standard spinal doses of hyperbaric bupivacaine used in our practice (⩾10.5 mg), there were higher odds of inadequate surgical anesthesia in preterm parturients. When adjusting for potential confounders, low birth weight was the main factor associated with failure.     

The management of gastroschisis.

A review of gastroschisis treated at the Royal Alexandra Hospital for Children, Sydney, in the ten years between 1967 and 1976, was carried out. Early postoperative deaths occurred in those with poor general condition before and immediately after the operation. The presence of a gastrostomy appears to be most effective in the immediate postoperative period to assist in decreasing intraabdominal pressure. The results of three initial operative methods are discussed. The three procedures are the Gross method; prosthetic closure; and the Savage and Davey method of transverse incision and closure. The purpose of this paper is to suggest that the procedure described by Savage and Davey has been a most successful procedure in providing reliable and safe method of closure of gastroschisis, avoiding the complications and morbidity of staged closure using prosthetic material.     

Effect of time to surgical evaluation on the outcomes of infants with gastroschisis

PurposeOur goal is to identify the impact of time to surgical intervention on the outcomes of infants with gastroschisis.MethodsAfter institutional review board approval, we performed a retrospective review of the medical records of all infants admitted to our institution from 2001 to 2010. Transport, bowel stabilization, and closure times were defined as the time from birth to admission, admission to the first-documented operative intervention, and first operative intervention to abdominal closure, respectively. Outcomes included age at full enteral feeds, total parental nutrition days, ventilator days, and hospital length of stay. Multivariate analysis was used to identify independent predictors of the outcomes.ResultsOne hundred eighteen infants with gastroschisis were included in our study. Transport and bowel stabilization times were not predictive of any outcome. However, the time to abdominal wall closure and postnatal gastrointestinal complications were independently predictive of age at full enteral feeds, total parenteral nutrition days, and hospital length of stay.ConclusionTime to surgical evaluation/bowel stabilization was not predictive of any clinically relevant outcomes in infants with gastroschisis. These data demonstrate that potential benefits from prenatal regionalization of infants with gastroschisis are not supported by decreased time to operative intervention.     

Outcome of neonates with gastroschisis at different gestational ages using a national database

Background/purpose

The optimal time for delivery of neonates with a prenatal diagnosis of gastroschisis (GS) is controversial. We compared the outcomes for GS at three different gestational ages (GAs), 33–34 weeks, 35–36 weeks, and ≥ 37 weeks.

Outcome of gastroschisis: a 20-year case review of infants with gastroschisis born in Galveston, Texas

Background/Purpose

In the past decade, the preferred method of closure of gastroschisis at our institution has been staged reduction using a silo with repair on an elective basis (SR) rather than primary surgical closure (PC). We performed a 20-year case review of infants with gastroschisis at a university hospital to compare these shifts in management and to determine factors affecting outcome.

Methods

Seventy-two cases were reviewed from 1983 to 2003. Times to first and full feeds were outcome variables for statistical analysis.

Results

The prevalence of gastroschisis increased from 0.03% to 0.1% since 1983. Patients had low birth weights (mean = 2294 g) and were borderline premature (mean = 35.8 weeks). Only 3% of the infants were African American. There was a high rate of cesarean deliveries (57%). Ten patients (15%) had gastroschisis complicated by liver herniation, intestinal atresia(s), and/or necrosis/perforation. Most patients were managed by SR (67%). Eight percent of the infants died, 9% developed necrotizing enterocolitis, and 50% had other gastrointestinal complications. Twenty-seven percent of the infants managed with SR did not need initial mechanical ventilation. However, the patients who underwent SR were ventilated longer after birth as compared with those who underwent PC (P < .08). Infants with a complicated gastroschisis had significantly longer times to first and full feeds (P < .001). Patients managed with SR took significantly longer to reach full feeds (P = .001), and there was a trend of starting feeds later (P = .06). When patients with a complicated gastroschisis were excluded, the differences between the SR and PC groups were even greater (P = .01; P < .001).

Conclusions

In our patient population, the prevalence of gastroschisis increased by more than 400% since 1983. The defect was rare in African-American infants. Management by SR was associated with longer ventilation times and longer times to first and full feeds for both uncomplicated and complicated gastroschisis cases.     

The influence of donor age on graft survival.

Recent papers report differing conclusions concerning use of kidneys from different donor age groups. We analyzed graft survival of 652 consecutive cadaver kidney donor-recipient pairs. Overall cumulative graft survival was 45 per cent at two years post transplantation. Kidneys from donors aged less that fifteen, sixteen to thirty. thirty-one to forty-five, and forty-six to sixty years had a cumulative graft survival of 51, 44, 39, and 40 percent, respectively. The difference is not statistically significant. When both donor and recipient ages are controlled, the pediatric aged kidney may be superior in the pediatric recipient or the older normotensive adult recipient. Use of properly selected cadaver kidneys in patients of all age ranges is encouraged.