South Dakota Perinatal Association (SDPA) 40th Annual Conference September 10-11, 2015

Gastroschisis Case Review Michael McNamara, DO Sanford 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

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

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