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Increased perinatal mortality with gestational at delivery in cases with gastroschisis: The tree masking the forest.

Editorial comment

In the January issue of AJOG, Sparks et al strengthen the growing perception that elective preterm delivery is beneficial to fetuses with gastroschisis.

They studied retrospectively all 860 singleton pregnancies with fetal gastroschisis delivered between 24 0/7 and 39 6/7 weeks in the United States in 2005 and 2006. They confirm data gathered in the literature in this high-risk population with 4.8% and 8.3% stillbirth and infant death rates respectively. They do demonstrate that the prospective risk of stillbirth and risk of fetal/infant death increases with each additional week after 35 completed weeks’, culminating at 39 weeks.

This is the biggest of several iconoclast studies that are shaking the wide spread conviction that a baby carrying a malformation mandating immediate neonatal surgery is best delivered as close to term as possible. A conservative approach is usually justified by wishing for bigger and more mature neonates to sustain neonatal surgery. However, the two main sources of additional mortality and morbidity in this severe fetal condition and that are likely to increase with gestation are growth restriction as well as some degree of ischemia of the herniated bowel often classified under “complex gastroschisis” cases. These occur in up to 30% and 15% of cases respectively.

Therefore, although the increase in perinatal mortality is an undisputable fact strongly illustrated by this large cohort study, it is very much the tree masking the forest of poorly recognized warnings of fetal distress in this condition. Intensive monitoring of these fragile fetuses in the third trimester is not standardized nor universal. Although the methodology used the analysis of birth certificates and does not allow for relevant management details, the results of this study should be an incentive to better monitor fetuses with gastroschisis with a liberal strategy of elective prematurity in cases with sga, decreased amniotic fluid volume as well as with changes in the ultrasound appearance of the bowel loops. Secondary bladder herniation has also been shown to increase perinatal death. The mode of delivery of fetuses with gastroschisis is still a controversial issue. These cases represent 0.04% of all deliveries, and it might therefore be futile to eagerly advocate for a trial of labor for these fragile preterm fetuses to decrease cesarean section rates.

 

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Commentaries by Editor Prof. Jim Thornton