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Gastroschisis occurs in approximately 1 of every 2,000 live
births, making it a relatively "common" congenital
anomaly. In fact, its incidence seems to be increasing in recent
years, for reasons unknown. There seems to be a relationship
with young maternal age, although it can occur at any age. At
our institution, we treat 6-10 infants with gastroschisis every
CAN BE DONE BEFORE BIRTH?
Gastroschisis can be diagnosed with fairly good accuracy from
the 14th week of gestation (3 months). It is now possible to
intervene during pregnancy for a number of anomalies (see for
example twin-to-twin transfusion syndrome). It would
be tempting, therefore, to try and treat the fetus with gastroschisis
before birth. However, extensive research has shown that patients
are best treated after they are born, and that most in
utero interventions would be too risky for mother and child.
We can intervene in other ways,
though: with advance knowledge of an abdominal wall defect, it
is possible to change the plans for delivery of the baby. One
can change the mode, place and time of delivery.
1. Mode of delivery
If intestines and other organs
are outside the abdomen, it would seem logical that they would
be at an increased risk of being damaged during normal delivery.
Some have therefore advocated Cesarean section ("C-section")
for all cases of gastroschisis and omphalocele. In fact, the
risk of injury is only theoretical, and vaginal delivery does
not put the baby at an increased risk of complications. For that
reason, most (although not all) physicians now recommend normal
delivery, even for gastroschisis, unless there are obstetrical
reasons to proceed with a C-section.
2. Place of delivery
As long as he or she is inside
the womb, the fetus with a gastroschisis is relatively well shielded
from trauma and complications. After birth, however, the exposed
intestines have to be protected from direct trauma, dehydration
and infection. The baby can be safely transported to a treatment
center, as long as certain precautions are taken. However, if
the diagnosis of gastroschisis has been made beforehand, it would
seem logical to have the baby be born directly in such a treatment
center (i.e., a center with a neonatal intensive care unit and
immediate access to a pediatric surgery service). Therefore,
we generally recommend that, if you are pregnant with a fetus
with gastroschisis or omphalocele, you plan to deliver in such
a tertiary institution. Your care will likely be transferred
to a Maternal-Fetal Medicine specialist at our institution, to
facilitate the transition to peri- and postnatal care.
3. Time of delivery
One of the concerns with gastroschisis
is that the exposed bowel becomes so damaged, that function is
impaired and the baby may end up staying in the intensive care
for a long time. It is known that many infants with gastroschisis
have what appears to be damaged bowel, with very thick, rigid
loops of intestines containing a "peel" (see picture). One of the theories
for this peel (and
for the fact that some babies have little or no peel at all)
is that prolonged exposure of the bowel to the amniotic fluid causes progressive damage.
In other words, limiting the amount of time that the bowel is
floating in this fluid (or even diluting that fluid by infusing
sterile saline water inside the womb) could theoretically decrease
the amount of peel and intestinal damage.
Many centers have therefore recommended
early delivery (between 35 and 37 weeks of gestation, instead
of the normal 40 weeks). Unfortunately, there are no good scientific
studies proving the benefits of this. In fact, at our institution,
we have reviewed all babies born with gastroschisis in the last
10 years, and have found no benefit at all of early delivery.
For that reason, we recommend that your baby be born as close
to term as possible.