South Dakota Perinatal Association (SDPA)

40th Annual ConferenceSeptember 10-11, 2015

GastroschisisCase Review

Michael McNamara, DOSanford Maternal Fetal Medicine

Case Presentation

• 16 year old G1,P0• Presented at 14+4 weeks for care• History of tobacco use, +THC on intake• Ultrasound - gastroschisis

First ultrasound

First ultrasound

Gastroschisis

• Greek, “belly cleft”• Incomplete closure of lateral folds• Occurs 6th week of gestation

Gastroschisis

• Quad screen– Elevated MSAFP– 10% of highly elevated MSAFP due to gastroschisis– Not seen if has 1st trimester screen

• Ultrasound– Free floating loops of small bowel– Physiological herniation of bowel until week 10

Gastroschisis

• Incidence– 1/2500– 1/1100 with age < 20 years old

• Risk factors– Age; four fold increase < 20 years old– Cigarette use; 2.1 fold increase risk– Medications – acetaminophen, pseudoephedrine– Drugs – Cocaine, marijuana, methamphetamines

Gastroschisis

Diagnosis• Ultrasound• Defect usually right of cord insertion• Cord inserts separately• No peritoneal membrane coverage• Multiple loops of free floating small bowel

Gastroschisis

• Complications antenatal• Fetal distress• Intrauterine growth restriction (IUGR) 30-70%• Associated anomalies 10-20%• Usually of the gastrointestinal tract

Gastroschisis

Survival• Greater than 90%• Cause of death– Bowel ischemia– Necrotizing enterocolitis (NEC)– Sepsis– Liver failure

Gastroschisis

Clinical Course• Consults– Pediatric Surgery– Neonatology– NICU tour– Pediatric Cardiology – suspected ASD

Gastroschisis

• Clinical Course• Pediatric Cardiology• Suspected ASD, suspected SVC emptying into

the coronary sinus

Gastroschisis

Clinical Course• Twice weekly antenatal testing (NST/BPP)• Growth ultrasound every two weeks• 35+5 weeks– Suspected IUGR with EFW < 10%, 1771 grams

(previous 18%)– FL and AC < 3%– Elevated umbilical artery doppler, SD of 5.1

(previous 3.88)

Gastroschisis 35+5

Gastroschisis

Delivery decision• 36+ weeks• IUGR, elevated SD ratio umbilical artery• Suspected cardiac abnormality• Discussion with Pediatric Surgery,

Neonatology, Pediatric Cardiology• Controlled delivery, middle of day / week• Primary cesarean

Gastroschisis

Delivery• Timing – 36 weeks vs 39-40 weeks– No difference in outcomes

• Route of delivery– Vaginal vs cesarean– No difference in outcomes– 39 % attempting vaginal have cesarean for fetal

distress

Gastroschisis

• Cesarean delivery at 36+2 weeks• Neonatal weight 2260 grams 4 lbs, 15 oz• Stabilized and taken to Main OR for evaluation

and repair

• Recurrence risk 2.4%