Prenatal Diagnosis and Perinatal Management of Gastroschisis: A Case Report

Introduction: Gastroschisis, a congenital abdominal wall defect, causes external protrusion of intestines and organs due to incomplete wall closure near the umbilicus. Accurate prenatal diagnosis through ultrasonography requires skilled operators to detect the defect and guide management. Early identification enables perinatal care planning to minimize complications, such as organ perforation, and optimize neonatal outcomes. This case report examines the prenatal diagnosis and management of gastroschisis in a primigravida, highlighting ultrasonography's role in clinical decision-making. Case Description: A 26-year-old primigravida at 34–35 weeks gestation was referred from Zubir Mahmud Regional Hospital with a prenatal diagnosis of gastroschisis. She reported severe abdominal pain and vaginal spotting for three weeks. Physical examination indicated stable hemodynamics, with obstetric findings including a fundal height of 26 cm, estimated fetal weight of 2015 g, left-sided fetal back, fetal heart rate of 142 beats/min, breech presentation, and no contractions. Speculum examination revealed a closed external cervical os, no dilation, negative fluxus, positive flour, protruding amniotic membranes, and a positive nitrazine test. Vaginal examination showed a posterior, soft cervix with no dilation or palpable fetal parts. The pregnancy was diagnosed with congenital gastroschisis, and a cesarean section was planned to prevent abdominal organ perforation. Conclusion: Gastroschisis, identified at 34–35 weeks gestation, necessitates early prenatal diagnosis to prepare for appropriate perinatal care. Cesarean delivery is a preferred strategy to reduce risks of organ damage, supporting improved neonatal outcomes in affected pregnancies.

In a prospective study in a tertiary university hospital we wanted to determine whether uterine electromyography (EMG) can differentiate between the active and latent phase of labor. Thirty women presenting at ≥37(0/7) weeks of gestation with regular uterine contractions, intact membranes, and a Bishop score <6. EMG was recorded from the abdominal surface for 30 min. Latent phase was defined as no cervical change within at least 4 h. Student's t-test was used for statistical analysis (p ≤ 0.05 significant). Diagnostic accuracy of EMG was determined by receiver operator characteristics (ROC) analysis. The integral of the amplitudes of the power density spectrum (PDS) corresponding to the PDS energy within the "bursts" of uterine EMG activity was compared between the active and latent labor groups. Seventeen (57%) women were found to be in the active phase of labor and 13 (43%) were in the latent phase. The EMG PDS integral was significantly higher (p = 0.02) in the active (mean 3.40 ± 0.82 μV) compared with the latent (mean 1.17 ± 0.33 μV) phase of labor. The PDS integral had an area under the ROC curve (AUC) of 0.80 to distinguish between active and latent phases of labor, compared with number of contractions on tocodynamometry (AUC = 0.79), and Bishop score (AUC = 0.78). The combination (sum) of PDS integral, tocodynamometry, and Bishop score predicted active phase of labor with an AUC of 0.90. Adding uterine EMG measurements to the methods currently used in the clinics could improve the accuracy of diagnosing active labor.

Gastroschisis is a congenital abdominal wall defect, thought by many to represent a disruption in intrauterine blood flow, where there is herniation of abdominal organs. Dietary intake is an important environmental factor that has been implicated in the development of many diseases. Omega-6 polyunsaturated fatty acids (PUFAs) are nutrients that are substrates for eicosanoid and cytokine synthesis and prone to oxidation, and play a role in modulating inflammation, immune function, and vascular system development. This pilot case-control study explored the association of dietary intake of the omega-6 PUFA linoleic acid with risk of gastroschisis. Between 2008 and 2011, we recruited 13 pregnant women in mid-gestation who were referred to the UCSD Prenatal Center for evaluation of an abnormal alpha-fetoprotein (AFP) test and subsequently identified as carrying a baby with gastroschisis. Nine controls were selected from a false positive AFP or from the UCSD prenatal clinic. Maternal dietary intake was collected via repeated food record during the last 20 weeks of gestation. Logistic regression was used to test the association between dietary intake of linoleic acid and odds of gastroschisis. Dietary intake of linoleic acid was associated with increased odds of gastroschisis (OR = 1.72; 95% CI: 1.08, 2.74; P = 0.02). A higher maternal intake of omega-6 PUFAs may increase the risk of having a baby with gastroschisis. The mechanism by which this occurs may be via inflammatory processes and oxidative stress leading to a vascular disruption. More research is needed including studies investigating integrated markers of PUFA status or inflammatory markers.

Abdominal wall defects (AWDs) represent a wide spectrum of congenital anomalies which are characterized by a herniation of abdominal organs through a pathologic opening in the abdominal region. The author describes a 29-year-old pregnant woman who was prenatally found to have a living female fetus with a giant omphalocele and a spinal deformation in the lumbosacral region. An evisceration of the abdominal contents into the amnionic cavity was visible. Based on USG findings the limb-body wall complex was suggested. An amniocentesis was performed and a genetic testing identified a chromosome 17q23.1–q23.2 duplication. As the fetal anomaly was considered incompatible with life, a medical termination of the pregnancy was carried out. Postmortem examination of the fetus revealed a huge abdominoschisis with a complete evisceration of the liver, stomach, small and large intestines, spleen, and the right kidney. A severe left-sided scoliosis deformity of the spine with crooked trunk was evident. The gross findings shared the features of omphalocele and limb-body wall complex with no postnatal life expectancy. Most fetal AWDs have poor prognosis. The pathology of these conditions differ greatly and require specific prenatal evaluation and pregnancy management for each entity. Accurate assessment of AWDs will allow the identification of isolated forms with better clinical outcomes compared to associated multiple malformations with chromosomal anomalies or genetic syndromes.

IntroductionComplications following Cardiopulmonary resuscitation (CPR) are rare and usually follows a vigorous CPR or in special cases like pregnancy are due to lack of knowledge and clinical practice of how to preform CPR in pregnancy. One of this complication is diaphragmatic rupture with herniation of abdominal organs. Surgical intervention needs to be planned carefully in multidisciplinary team approach and requires fine surgical techniques for better outcome. There are few reported cases of diaphragmatic rupture after Cardiopulmonary resuscitation but none in pregnant woman.Case presentationWe report a rare case of diaphragmatic rupture in a 29-year-old pregnant patient who experienced a full-blown diaphragmatic defect and herniation of the abdominal organs into the thoracic cavity, as a complication of CPR. Following careful assessment and diagnosis, the patient underwent urgent laparotomy with reduction of the contents and primary closure of the defect. One year follow up was satisfactory. To the best of our knowledge, this is the first reported case of diaphragmatic rupture with herniation of the abdominal organs following CPR in a pregnant woman in the literature.ConclusionThe application of external cardiac massage through CPR is a life-saving procedure for the management of cardiac arrest. Common complications related to CPR include rib fractures, sternal fractures and haemothorax. Diaphragmatic rupture with herniation of the abdominal organs is a rare complication, having been reported only once in the literature (Sabzi F, Faraji R, Tanaffos 16:170–172, 2017); however, it represents a serious and life-threating event. Thus, careful evaluation of the patient by a multidisciplinary team and prompt intervention is recommended in order to improve outcomes.

Management of neonates with long gap esophageal atresia (LGEA) is one of the most challenging situations facing pediatric surgeons. Delayed anastomosis after internal traction for esophageal lengthening was reported as a useful technique for long gap cases. Additionally, the use of near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) has gained popularity in pediatric surgery, especially for blood perfusion validation. We report a novel technique for safe and secure anastomosis for LGEA in the neonatal period using internal traction and ICG-guided NIR fluorescence. A pregnant woman with polyhydramnios was admitted to the department of obstetrics in our hospital. At 29 weeks of gestation, ultrasound showed mild polyhydramnios and absence of the fetal stomach. A male neonate was born at 38 weeks of gestation with 21 trisomy. EA (Gross type A) was diagnosed based on an X-ray study that showed the absence of gastric bubble with a nasogastric tube showing the "coil-up" sign. Thoracoscopic internal traction and laparoscopic gastrostomy were performed on day 4 after birth. We confirmed the distance between the upper pouch and lower pouch on X-ray. On day 16 after birth, thoracoscopic anastomosis was performed. We successfully performed esophageal anastomosis without tearing the esophageal wall. Blood perfusion of the upper and lower pouch was validated after anastomosis using ICG-guided NIR fluorescence. Delayed anastomosis for LGEA in the neonatal period using internal traction and ICG-guided NIR fluorescence is safe and feasible.

The aim of this nationwide population-based case–control study was to assess the incidence of inguinal hernia (IH) among patients with congenital abdominal wall defects. All infants born with congenital abdominal wall defects between Jan 1, 1998, and Dec 31, 2014, were identified in the Finnish Register of Congenital Malformations. Six controls matched for gestational age, sex, and year of birth were selected for each case in the Medical Birth Register. The Finnish Hospital Discharge Register was searched for relevant diagnosis codes for IH, and hernia incidence was compared between cases and controls. We identified 178 infants with gastroschisis and 150 with omphalocele and selected randomly 1968 matched, healthy controls for comparison. Incidence of IH was significantly higher in gastroschisis girls than in matched controls, relative risk (RR) 7.20 (95% confidence interval [CI] 2.25–23.07). In boys with gastroschisis, no statistically significant difference was observed, RR 1.60 (95% CI 0.75–3.38). Omphalocele was associated with higher risk of IH compared to matched controls, RR 6.46 (95% CI 3.90–10.71), and the risk was equally elevated in male and female patients.Conclusion: Risk of IH is significantly higher among patients with congenital abdominal wall defects than in healthy controls supporting hypothesis that elevated intra-abdominal pressure could prevent natural closure of processus vaginalis. Parents should be informed of this elevated hernia risk to avoid delays in seeking care. We also recommend careful follow-up during the first months of life as most of these hernias are diagnosed early in life.What is Known:• Inguinal hernia is one of the most common disorders encountered by a pediatric surgeon.• Prematurity increases the risk of inguinal hernia.What is New:• Children with congenital abdominal wall defects have a significantly higher risk of inguinal hernia than general population.• Families should be informed of this elevated hernia risk to avoid delays in seeking care.

To evaluate maternal and perinatal outcomes in women undergoing labor induction with an unfavorable cervix according to duration of oxytocin administration in the latent phase of labor after ruptured membranes. This was a secondary analysis of a randomized multicenter trial in which all cervical examinations from admission were recorded. nulliparas at or beyond 36 weeks of gestation undergoing induction with a cervix of 2 cm or less dilated and less than completely effaced. The latent phase of labor was defined as ending at a cervical dilation of 4 cm and effacement of at least 90%, or at a cervical dilation of 5 cm regardless of effacement. A total of 1,347 women were analyzed. The overall vaginal delivery rate was 63.2%. Most women had exited the latent phase after 6 hours of oxytocin and membrane rupture (n=939; 69.7%); only 5% remained in the latent phase after 12 hours. The longer the latent phase, the lower the vaginal delivery rate. Even so, 39.4% of the 71 women who remained in the latent phase after 12 hours of oxytocin and membrane rupture were delivered vaginally. Chorioamnionitis, endometritis, or both, and uterine atony were the only maternal adverse outcomes related to latent-phase duration: adjusted odds ratios (95% confidence intervals) of 1.12 (1.07, 1.17) and 1.13 (1.06, 1.19), respectively, for each additional hour. Neonatal outcomes were not related to latent-phase duration. Almost 40% of the women who remained in the latent phase after 12 hours of oxytocin and membrane rupture were delivered vaginally. Therefore, it is reasonable to avoid deeming labor induction a failure in the latent phase until oxytocin has been administered for at least 12 hours after membrane rupture. III.

The use of epidural for vagina birth after caesarean section is contentious even in established Labour and Delivery Units because of concerns regarding maternal and fetal wellbeing following the occurrence of a uterine rupture as epidural analgesia may obscure the pain following such. Epidural analgesia has remained the major option for the management of pain in labour. Recently, there has been anecdotal evidence of increase in the use of epidural in labour and consequently brought to the fore a wide variety of case-mix on the floor. We report a case of labour epidural analgesia for vaginal birth after caesarean section (VBAC). The Parturient was a 28 year old booked G2P1+0, gestational age 37weeks in latent phase of labour. She had a previous caesarean section done for fetal distress and a lower uterine incision was used for the delivery of the fetus.Epidural analgesia was requested by the parturient and this was established in the sitting position using a size 18g Tuohy needle observing unit protocol. It was then activated with 8ml of 0.125% plain bupivacaine and then 5ml after 2 minutes. We ensured safety by ensuring close monitoring of the fetus using a cardiotocography and also of the parturient using a multiparameter monitor. At 4hours 40 minutes after admission, she had an unassisted vaginal delivery of a live 2.75kg male neonate with an Apgar score of 8 in 1 minute and 9 in 5. Baby was healthy and normal and the third stage of labour was managed using 10 international units of intravenous oxytocin and 20IU oxytocin in intravenous fluid 5% dextrose water.Conclusion: Women for VBAC should not be denied epidural labour analgesia. Monitoring gadgets and recruiting more manpower should be advocated especially in emerging Labour and Delivery Units and engender resource-constrained environment.

IntroductionWhen women with a previous cesarean section and an unfavorable cervix have an indication for delivery, the choice is to induce labor or to perform a cesarean section. This study aims to assess the effectiveness and safety of a balloon catheter as a method of induction of labor in women with one previous cesarean section and an unfavorable cervix compared with an elective repeat cesarean section.Material and methodsWe performed a prospective cohort study in 51 hospitals in the Netherlands on term women with one previous cesarean section, a live singleton fetus in cephalic position, an unfavorable cervix and an indication for delivery. We recorded obstetric, maternal and neonatal characteristics. We compared the outcome of women who were induced with a balloon catheter with the outcome of women who delivered by elective repeat cesarean section. Main outcomes were maternal and neonatal morbidity. Mode of delivery was a secondary outcome for women who were induced. Adjusted odds ratios (aOR) were calculated using logistic regression, adjusted for potential confounders.ResultsAnalysis was performed on 993 women who were induced and 321 women who had a repeat cesarean section (August 2011 until September 2012). Among the women who were induced, 560 (56.4%) delivered vaginally and 11 (1.1%) sustained a uterine rupture. Composite adverse maternal outcome (uterine rupture, severe postpartum hemorrhage or postpartum infection) occurred in 73 (7.4%) in the balloon and 14 (4.5%) women in the repeat cesarean section group (aOR 1.58, 95% confidence interval [CI] 0.85‐2.96). Composite adverse neonatal outcome (Apgar score <7 at 5 minutes or umbilical pH <7.10) occurred in 57 (5.7%) and 10 (3.2%) neonates, respectively (aOR 1.40, 95% CI 0.87‐3.48). Women who were induced had a shorter postpartum admission time (2.0 vs 3.0 days (P < 0.0001)).ConclusionsIn women with a previous cesarean section and a need for delivery, induction of labor with a balloon catheter does not result in a significant increase in adverse maternal and neonatal outcomes as compared with planned cesarean section.

Are increased fetal movements during pregnancy a predictor of neonatal adverse outcomes?

ISUOG Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals.

The aim of this study was to assess the influence of the cesarean section scars on the mean pulsatility index (PI) of the uterine artery Doppler between 20 and 34 weeks of gestation. A secondary objective was to assess the association between previous cesarean section and adverse maternal/perinatal outcomes. A retrospective cohort study was conducted with pregnant women who had their deliveries between March 2014 and February 2023. PI of the uterine arteries Doppler was performed transvaginally between 20-24 weeks and transabdominally between 28-34 weeks. The following variables were considered adverse perinatal outcomes: birth weight <10th percentile for gestational age, preeclampsia, premature birth, placental abruption, perinatal death, postpartum hemorrhage, neonatal intensive care unit (NICU) admission. A total of 479 pregnant women were included in the final statistical analysis, being that 70.6% (338/479) had no (Group I) and 29.4% (141/479) had at least one previous cesarean section (Group II). Pregnant women with a previous cesarean had higher median of mean PI (1.06 vs. 0.97, p=0.044) and median MoM of mean PI uterine arteries Doppler (1.06 vs. 0.98, p=0.037) than pregnant women without previous cesarean section at ultrasound 20-24 weeks. Pregnant women with a previous cesarean section had higher median of mean PI (0.77 vs. 0.70, p<0.001) and mean MoM PI uterine arteries Doppler (1.08 vs. 0.99, p<0.001) than pregnant women without previous cesarean section at ultrasound 28-34 weeks. Pregnant women with ≥2 previous cesarean sections had a higher median of mean PI uterine arteries Doppler than those with no previous cesarean sections (1.19 vs. 0.97, p=0.036). Group II had a lower risk of postpartum hemorrhage (aPR 0.31, 95% CI 0.13-0.75, p=0.009) and composite neonatal outcome (aPR 0.66, 95% CI 0.49-0.88, p=0.006). Group II had a higher risk of APGAR score at the 5th minute <7 (aPR 0.75, 95% CI 1.49-51.29, p=0.016). The number of previous cesarean sections had a significant influence on the mean PI uterine arteries Doppler between 20-24 and 28-34 weeks of gestation. Previous cesarean section was an independent predictor of postpartum hemorrhage and APGAR score at the 5th minute <7. Pregnancy-associated arterial hypertension and number of previous deliveries influenced the risk of composite neonatal outcome, but not the presence of previous cesarean section alone.

We aim to explore whether the long inter-pregnancy interval (IPI) modifies the association between previous cesarean section (CS) and adverse maternal and neonatal outcomes in a population with a high rate of CS and a longIPI. Adverse maternal and neonatal outcomes were compared between the previous CS and previous vaginal delivery groups. Logistic models were used to adjust for potential confounding factors and calculate the odds ratios (ORs) and 95 % confidence intervals (CIs). The interaction model and stratified analyses were used to evaluate the modifications of IPIs on the associations between previous CS and maternal and neonatal outcomes. Compared with previous vaginal delivery, previous CS was associated with increased risks of uterine-related complications (aOR=1.57, 95 % CI 1.25-1.98), but with decreased risks of preterm birth (aOR=0.73, 95 % CI 0.63-0.85) and severe neonatal adverse outcomes (aOR=0.59, 95 % CI 0.46-0.78). There are synergistic biological interaction effects of previous CS and a long IPI (>60months) on the risks of placental-related complications (RERI=0.32, 95 % CI 0.05-0.58; AP=0.39, 95 % CI 0.03-0.76) but an antagonistic biological interaction effect on the risk of preterm birth (RERI=-0.35, 95 % CI -0.68 to-0.01; AP=-0.09, 95 % CI -0.68 to-0.03). Previous CS was associated with increased risks of adverse maternal outcomes but decreased risks of certain adverse neonatal outcomes. Prolonged IPIs might not attenuate the adverse effects of previous CS on mothers, and might adversely exert harm on newborns.

Gastroschisis is a congenital abdominal wall defect where there is herniation of abdominal organs. Optimal maternal nutritional intake, in particular, fatty acids, are vital for proper growth and development of the fetus. This pilot case-control study explored the association of several biomarkers of fatty acids and gastroschisis. Between 2008 and 2011, we recruited 13 pregnant women in mid-gestation who were referred to the UCSD Prenatal Center for evaluation of an abnormal maternal serum alpha-fetoprotein (MSAFP) test and subsequently identified as carrying a baby with gastroschisis. Nine controls were selected from a false positive MSAFP or from the UCSD prenatal clinic. At enrollment, maternal blood was drawn for analysis of fatty acids. Mann-Whitney-Wilcoxon tests were used to test for mean differences between erythrocyte fatty acid biomarkers and the fatty acid lipogenic (palmitic acid: linoleic acid) and desaturation (palmitoleic acid: palmitic acid) indices and gastroschisis. Mothers carrying a baby with gastroschisis and gastroschisis babies had consistently higher levels of palmitoleic acid (all P's < 0.05), gastroschisis mothers had lower levels of oleic acid during pregnancy and at delivery, and higher levels of DHA at delivery (all P's < 0.05). The lipogenic index was significantly lower at delivery for gastroschisis mothers (P < 0.05) and the desaturation index was consistently higher in gastroschisis mothers and babies (all P's < 0.01). These findings suggest that early maternal inflammation possibly resulting from an imbalance of fatty acids, leading to a vascular disruption, may be the underlying mechanism responsible for at least some cases of gastroschisis.