11/71. Transabdominal amnioinfusion to avoid fetal demise and intestinal damage in fetuses with gastroschisis and severe oligohydramnios. BACKGROUND/PURPOSE: Despite dramatic improvement in survival rate for neonates with gastroschisis, significant postoperative morbidity and a low mortality rate still occur. Furthermore, even in recent publications, some fetal death has been reported. Does this mean that antenatal diagnosis of gastroschisis is a missed opportunity? In fact, decreased amniotic fluid (AF) volume is observed in some fetuses with gastroschisis. However, oligohydramnios is associated with an increased risk of fetal suffering. When severe oligohydramnios is observed, intrapartum amnioinfusion, to restore AF volume, may help avoid fetal complications. methods: Two fetuses with gastroschisis and severe oligohydramnios were treated antenatally with amnioinfusion of saline solution. In one case, fetal heart beat decelerations were observed at 27 weeks' gestation among with the oligohydroamnios and serial transabdominal amnioinfusions were performed. In the second case, severe oligohydramnios was observed at 31, weeks and an amnioinfusion was performed. The 2 babies were delivered at 31 and 34 weeks, respectively. RESULTS: In both cases, exteriorized bowel was nearly normal at birth, and primary closure could be performed. Outcome was favorable, and they were discharged home on day 43 and day 54, respectively. CONCLUSIONS: Because fetuses with gastroschisis and oligohydramnios are part of a particular high-risk group, serial ultrasound examination and computerized fetal heart beat monitoring are necessary during the third trimester. In selected cases of gastroschisis associated with severe oligohydramnios, serial amnioinfusion may be required. ( info) |
12/71. Complications of intrauterine intervention for treatment of fetal obstructive uropathy. The intrauterine surgical placement of vesicoamniotic shunts in the treatment of fetal obstructive uropathy associated with prune-belly syndrome to avoid such complications as renal damage and oligohydramnios remains controversial. We present a case of an infant born with prune-belly syndrome at 33 weeks and 5 days of estimated gestational age to a mother of two by vaginal delivery after a pregnancy complicated by fetal obstructive uropathy with attempted intrauterine intervention. After sonographic and laboratory diagnostic and prognostic evaluations, an intrauterine procedure was performed in which a vesicoamniotic shunt was placed under ultrasound guidance. Complications included dislodgment of the initial shunt, with a failed subsequent attempt at placement, oligohydramnios, preterm labor and delivery, and traumatic gastroschisis through the surgical abdominal wall defect. His hospital stay was further complicated by chronic renal insufficiency, prematurity, respiratory distress, bowel malrotation, an episode of gram-negative sepsis with enterobacter cloacae, signs of liver failure, an exploratory laparotomy for severe enterocolitis, and orchiopexy for bilateral undescended testes. At present, it is unclear whether vesicoamniotic shunt placement can provide any significant improvement in the morbidity or mortality for patients with prune-belly syndrome. A large, prospective, randomized trial is needed to determine its efficacy. ( info) |
13/71. Functional urinary tract obstruction developing in fetuses with isolated gastroschisis. OBJECTIVE: To evaluate the frequency and natural history of urinary tract abnormalities developing in fetuses presenting with initially isolated gastroschisis. methods: Serial ultrasounds were performed prospectively on fetuses identified by our prenatal diagnosis program as having a gastroschisis. When abnormalities in the urinary tract were identified prenatally, newborns were evaluated by a pediatric urologist. RESULTS: Over a 1-year period four out of 12 fetuses with gastroschisis developed deformations of the urinary tract. In three fetuses the bladder herniated through the abdominal wall defect. Two also had upper tract dilatation. A fourth fetus developed bilateral hydronephrosis with a normally situated bladder. Once the gastroschisis was repaired none of the newborns had evidence of structural obstruction of the urinary tract, however, hydronephrosis with or without reflux persisted for several months. CONCLUSIONS: Deformations of the fetal urinary tract can develop secondary to gastroschisis. They do not appear to represent separate malformations and evaluation with fetal karyotyping may not be indicated. When hydronephrosis is present ongoing urologic evaluation of the neonate is indicated. ( info) |
14/71. Persistent mydriasis following intravenous atropine in a neonate. A neonate whose mother had recently taken amitriptyline developed fixed dilated pupils after a modest dose of intravenous atropine. Interaction of atropine with neonatal amitriptyline levels is suggested and evidence of neonatal effects from maternal antidepressant use is examined. There were no neurological sequelae, and the neonate's pupils became reactive again after 7 h. ( info) |
| Left-sided gastroschisis has rarely been reported. From August 1987 to April 1998, 73 cases of gastroschisis were treated at the Pediatric Surgical Unit, Department of Surgery, Ratchaburi Hospital. The abdominal wall defect of only 2 cases occurred on the left side of the umbilicus. The 2 cases of left-sided gastroschisis were girls and were successfully treated by primary fascial closure. After 7 and 1 year follow-up the patients remain asymptomatic. ( info) |
16/71. Acute bowel perforation in a fetus with gastroschisis. gastroschisis is a congenital anomaly with a reported incidence of 1 in 10,000 live births. Although prenatal diagnosis is more common with the widespread use of biochemical markers and obstetric ultrasound, the role of ultrasound in the identification of the fetus that might need early intervention has not been established. Acute bowel perforation was diagnosed by ultrasound at 34 weeks gestation in a fetus with gastroschisis. An immediate cesarean section was performed, followed by repair with primary closure. The neonatal outcome was favorable. The post-partum findings, including bowel pathology, confirmed the antenatal diagnosis. Acute bowel perforation can be diagnosed antenatally. Immediate intervention, before further bowel injury occurs, might enhance the ability of the surgeon to perform primary closure and obtain a favorable outcome. ( info) |
17/71. Unsatisfactory experience with 'minimal intervention management' for gastroschisis. PURPOSE: The authors report, for cautionary reasons, their trial with "minimal intervention management" for gastroschisis. After the successful innovative experience with this approach, which Bianchi and Dickson described, they utilized it in 4 consecutive patients. methods: In the delivery room a plastic bag was placed over the intestines, which rested in a dependent position to reduce edema. The stomach was decompressed and the patients kept warm. Intravenous fluid at a maintenance rate was given. After about 5 hours an attempt at closure was undertaken in the newborn intensive care unit without anesthesia. An assistant lifted the anterior abdominal wall by applying upward traction on the umbilical cord. Over about 25 minutes the intestines were placed in the coelom, which was closed with a single suture. RESULTS: The outcome was uncomplicated in the first of 4 consecutive patients. The second patient had abdominal compartment syndrome requiring a silo and subsequent resection and has chronic malabsorption 16 months later. The third had an enterocutaneous fistula at 5 weeks that required a small bowel resection. Bedside closure was abandoned in the final case because too much resistance was encountered. She underwent primary repair in the operating room and eventually died of sepsis with intestinal dysmotility. CONCLUSIONS: The "minimal intervention approach" can be effective in some patients who have gastroschisis. This experience suggests that selection criteria are needed before this method can be recommended. ( info) |
18/71. Silo reduction of giant omphalocele and gastroschisis utilizing continucous controlled pressure. A method is described utilizing continuous controlled pressure to achieve smooth, rapid, and safe silo reduction of an anterior abdominal-wall defect. A metal tube with larger wheels at each end is suspended by runners and counterweights to slowly roll the silo and squeeze the contents into the abdominal cavity. ( info) |
| BACKGROUND: gastroschisis occurs in 1 of every 4000 live births resulting in a neonate with an abdominal wall defect that requires repair. Surgical correction has high survival rates. CASE: An 18-year-old primigravida had a fetus with gastroschisis detected by ultrasound performed for elevated maternal serum alpha-fetoprotein. Subsequent ultrasound found resolution of the classic sonographic features of gastroschisis and evidence of intestinal obstruction. At birth, no obvious abdominal wall defect was seen. laparotomy was done because of clinical and radiographic evidence of bowel obstruction, and we found significant bowel loss that resulted in short-bowel syndrome. CONCLUSION: gastroschisis diagnosed antenatally can resolve in utero causing necrosis of portions of the small and large bowels, causing short-bowel syndrome and increased morbidity and mortality. ( info) |
20/71. gastroschisis and Hirschsprung's disease: a rare combination. The authors report on a neonate with gastroschisis repaired at birth who later had abdominal distension, emesis, feeding intolerance, and an abnormal stooling pattern. Total colon and partial small bowel aganglionosis (TCAS), or Hirschsprung's disease, was diagnosed subsequently. This is the first report of this combination of gastrointestinal anomalies. J Pediatr Surg 36:638-640. ( info) |