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MRCOG PART 2 SBAs and EMQs

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Essay 355

gastroschisis Posted by HAnaa B.

A

The result of the scan should be explained to the patient in clear sensitive way in simple words excluding any blam culture. Patient is asked to have her partner to attend the explanation if she wishes.

The scan findings that her baby is having  an opening in his abdominal  wall and the bowel loops is freely mobile in the amniotic fluid  at the site of the umbilicus , this condition may be accompanied by other structural anomalies, with increase in the fluid around the baby, also her baby is expected to be smaller than usual .

There is no need for karyotyping as it has not associated with congenital anomalies. The survival is 80% with good prognosis if the defect is corrected immediately after delivery.

It has low risk of recurrence in the next pregnancy. But she is in need to be followed by scan more than usual to follow growth, amniotic fluids and intestinal loops. There is small risk that her baby may die in the uterus

She need joint counseling between surgeon and neonatologist.

Patient is offered the option of termination of her pregnancy before 23weeks if she wishes so.

B

Patient should know that she needs to deliver in a tertiary centre where facilities of immediate surgical correction of the defect are available.

The aim to go for vaginal delivery if there is no obstetric indication for CS.Controlled Arm during labor to guard against prolase of cord or intestinal loops, the intestinal loops should be covered by worm towel immediately after delivery. The resuscitation team should be available to close the defect and reduce the intestine before being gangrenous

Delivery should be conducted by senior physician with midwife .Good pain management should be offered  to help reassurance of the patient anxiety about her baby, continuous fetal monitoring is  used  

Posted by Sailaja C.

 

A) The ultrasound report could generate maternal anxiety. Sensitive and sympathetic approach is required in counseling preferably in the presence of partner or other family member.

 

The defect should be explained in a simple language that it is a defect in the abdominal wall next to the umbilicus through which loops of bowel escape and float in the amniotic fluid.

 

She should be informed that the outcome is good with 80% survival.

 

She should be explained that risk of abnormal karyotype is less than 1 % unless other structural abnormalities are detected.

 

Another detailed ultrasound scan should be arranged at tertiary centre to identify associated structural defects like cleft palate or diaphragmatic hernia.

 

She should be told that karyotype is not indicated in the absence of associated structural anomalies. In other defects are detected, karyotyping after amniocentesis is offered which is invasive, and associated with 0.5 to 1 % fetal loss rate above the background risk.

 

The maternal risks are informed which include poly hydramnios resulting in maternal discomfort and preterm delivery.

 

Neonatal and surgical team's are involved to explain about the prognosis and survival.

 

The fetal risks are explained which are IUGR, risk of prematurity and bowel torsion.

 

She should be informed that she may require frequent scans to monitor growth, liquor and bowel appearance.

 

She should be informed that there is a risk of sudden fetal death at term. Close monitoring in the third trimester after 34 weeks is required, by fetal heart rate tracings, ultrasound and umbilical artery doppler although the value of monitoring is uncertain.

 

She should be informed that early delivery is not indicated to reduce the exposure of bowel to amniotic fluid.

 

Term delivery at 37 weeks allows for earlier, definitive closure of the defect, and early oral feeding.

 

She should be explained that delivery is planned at a tertiary centre with neonatal surgical facilities.

Mode of delivery is vaginal in the absence of obstetrical indications for caesarean section.

 

The surgical correction would take place almost rapidly after the delivery and details of the procedure, risks and post operative stay are provided by the neonatal surgeon.

 

She should be informed that the recurrence risk is very low.

 

Written information is provided.

 

B)

 

The delivery should be planned at tertiary center equipped with the neonatal surgical facilities and staff.

Mode of delivery doesn't have any affect on outcome so vaginal delivery is anticipated in the absence of other indications.

 

When the woman goes in to labour especially in the odd hours, effective communication among various specialites ( anaesthesia, neonatology and neonatal surgery) is required to enable surgical correction in the immediate post natal period.

 

The woman and the family are adequately supported during labour to alleviate their anxiety.

Continuous electronic fetal monitoring is required.

 

The presence of neonatologist is summoned at the time of delivery.

 

Minimal handling of the bowel is required during delivery.As there is no protecting membrane over the bowel, sterile plastic bag containing warmed electrolyte and antibiotic solution should be kept ready.

 

 

Posted by Ana B.

The first step is to explain the ultrasound findings and deal with emotional upset. It is important to give an option of having her partner or someone with her.

Explanation of the condition in sensitive manner should be given, emphasising that the diagnosis of isolated gastroschisis is generally has a good prognosis with 80% of survival rate after successful primary surgery; also the risk of abnormal karyotype of less than 1 %. However, karyotype may be indicated if other anomalies are present.

The next step would be a referral to tertiary centre for more detailed scan to exclude multiple abnormalities, including cardiac scan. The meeting with multidisciplinary team could be set up at the same time. As there is a need for very early neonatal surgery within 12 hours after delivery, parents should have the opportunity to discuss this with paediatric surgeon, also with neonatologist with regards of neonatal care.

The woman should be aware is that the risk of associated anomalies is less than 10%; and in the presence of no associated anomalies she would be advised to have a close monitoring in third trimester, it means - more antenatal visits as there is a risk of unexplained IUD; and serial scans for IUGR, liquor volume and bowel morphology as there are risks of growth restriction and polyhydramnious.

The woman and her husband should be fully involved in decision-making process, have the opportunity to ask questions and have contact information and opportunity to discuss it again as may be difficult to apprehend all information in the first time.

It is important to reassure the parents there is a very low risk of recurrence in consequent pregnancies.

 

b) In case of isolated gastroschisis, the aim is for vaginal delivery following discussion with neonatal team.

Delivery should occur in the centre where neonatal medical and surgical expertise is available. Caesarean section has no benefit unless there are obstetric indications in discussion with senior obstetrician and according to the plan of care discussed antenatally with neonatalogy team.

Neonatologist should available immediately after delivery, and be aware of the patient with this condition at the beginning of labour.

Paediatric surgeon should be informed beforehand, as surgical repair is urgent procedure. Therefore intrapartum care is in strict coordination with neonatal team.

Continuous support during the labour by partner or family members should beencouraged. Delivery should be as gentle as possible, avoiding handling loops of bowel. Sterile bowel bag and neonatal resuscitation facilities should be kept available.

SEQ 355 Posted by Saud-ur R.
Gestroschisis is the fetal abdominal wall defect with a typical appearance like a clump of grapes due to free floating bowel with no covering membrane. The chances of having chromosomal abnormality is one to three percent. Ideally the woman should be counsel by multi-disciplinary team consists of consultant obstetrician, pead surgeon, neonatologist and expert midwife. A detail ultrasound at fetal medicine or tertiary level hospital should be offered to exclude associate anomaly like cardiac or other. She should be counsel in clear words with a sympathetic approach keeping in mind her anxiety and stress regarding the outcome of this pregency. She should be informed that gestroschisis when isolated is rarely associated with chromosomal abnormality. However, the fetus need more surveillance and regular growth scanning due to the high risk of fetal growth restriction, prematurity. intra utrine fetal death and oligo or polyhydramnios. Gestroschisis is not alone indication for termination of pregnancy . However, associated with bowel torsion which compromise the blood supply or associated with obstruction of atretic segment of intestine. Counselling regarding damage to bowel sarosa in contact with amniotic fluid should be explained for which the evedence is unclear. Counselling regarding repair, its complication and outcome should be given by the peadic surgeon. However, the presence of meconium in the amnotic fluid with peel formation will not effect the surgical outcome of repair. Patients should be give information regarding neonatal complications include not only reduction and closure of the gestroschisis but also atretic segment and critical shorting of the bowel. Information regarding short term complications like total parental nutrition , bowel dysfunction and neurodevelopmental delay especially where there is factor of fetal growth restriction.Parents should be counselled regarding recurrence which is very low. All these information given should be documented and back up by information leaflet which the patients should have to make an inform choices. Part B Fetus with gestoschisis should be delivered at a referral centre equipped with appropriate facility and staff. Cesarean section does not improve outcome.Gastroschisis is not an indiction for induction of labour These is some evidence that survival rate is high in fetuses subjected to labor. Thus in the absence of other complication vaginal delivery should be anticipated. Monitoring for intra partum fetal distress should be done.Good analgesia and continues support during labour wll help alot in relieving her anxiety Bowel should be handle carefully ,place them in a sterile plastic bag with isotonic solution. A skill resuscitator should be present at the time of delivery with the availability of cot at scbu if needed. Primary closure minimize the morbidity. A plan must be there for the prevention of heat and fluid loss. Associated bowel malformations should be assess. Primary Closure is achieved in 80 per cent of cases. Post Operative ventilation is generally require of 72 hours along with parental nutrition.When primary closure is not possible a silastic silo is created as with omphalocele.
Posted by Sweta P.

A)

Abnormal anomaly scan can generate a lot of anxiety for the mum, hence the approach should be sensitive and empathetic. If she is unaccompanied, an immedaite offer should be made to call partne/ family members.

The diagnosis should be explained in simple terms as in defect in abdomen through which free floating bowel herniating out, which usually has good prognosis of 80% but depends ont he size of defect and other organs herniationg out in which case the prognosis is poorer. Information regarding low recurrence risk should be given.

Associated structural and karyotypic abnormalities are rare but she should be offered a detailed fetal medicine scan to exclude them. Invasive prenatal testing is not required to confirm the diagnosis.

Multidisciplinary management is ancillary involoving neonatalogist, paediatric surgeons and specialist midwives. Immediate repair of defect is paramount to the management, which should be explained to the patient.

Serail growth ultrasound scans would be indicated to monitor the growth of the baby as can be associated with fetal growth restriction.

Previous obstetric history and medical history would help in making a decision regarding delivery. Previous caesarean section would need a repeat casarean section. If no risk factors, vaginal delivery should be aimed for with gentle handling of the free floating bowels.

Parents should be informed that the baby would be transferred tot he neonatal unit for intensive monitoring and immediate repair surgery. 

Information regarding availability of termination of pregnancy if she so wishes.

Parents should be given opportunity to ask questions and the verbal information should be backed with written information.

 

B)

Aim should be to deliver in a tertiary unit with facility of immediate neonatal resuscitation and paediatric surgery. Plan of delivery should be documented int he notes.

Maternal wishes, previous obstetric history and antenatal course should be considered for decision regarding mode of delivery.Vaginal delivery should be anticipated if the defect is small and if only bowel herniation is anticipated.

Continuous electronic fetal monitoring should be undertaken. An expereinced midwife should be involved in delivery to minimise the trauma and handling of exposed bowel.

Neonatalogist should be present for delivery and the exposed bowel should be covered with sterila plastic bag to minimise trauma. Immediate recourse to repair of the defect should be undertaken.

Posted by Nick M.

a.The first step is to explain the scan findings to the woman and her partner. This should be done in the presence of experienced midwife and if the woman is unaccompanied she should be given the option of contacting her partner, a family member or friend.

The woman should be informed that her baby has a defect in the abdominal wall close to where the umbilical cord inserts. The scan has shown babies bowl on the outside of the abdominal cavity. Simple diagrams may aid understanding.

She should be told that baby will need surgery to replace the bowel and close the defect. This will be done within 12 hours of birth. The woman should be reassured that survival is over 90% over 60% of babies only need one operation but baby will have a much longer stay in hospital.

The woman’s current obstetric history and past obstetric history should be reviewed. Particular attention should be paid to previous modes of delivery – as this will influence how this baby is delivered. Its also important to review any prenatal screening in this pregnancy, as this may influence the decision to undergo further invasive prenatal diagnosis. She should be informed that associated anomalies are rare but can occur in 10% of cases. The most common associated defects are cardiac.

The woman should be informed that there are no increased risks to her but babies with gastroschisis tend to be at an increased risk of being growth restricted. There is also an increased risk of intrauterine death particularly in the last trimester. Because of this, baby will be monitored with growth scans and dopplers every 2 weeks to check baby is growing properly. She should also be informed that baby has a long-term risk of bowel dysfunction related to the bowel being free in the amniotic fluid.

Her baby will need to be delivered in a hospital with paediatric surgical facilities. If baby is growing properly and blood flow in the umbilical cord is normal labour will be induced at 37 weeks aiming for vaginal delivery. The reason for delivery at 37 weeks is two-fold; There is an increased risk of still birth as the pregnancy progresses; Delivery at 37 weeks allows prompt surgical repair and resumption of oral feeding. She will need to be monitored continuously throughout labour because there is an increased risk of fetal cardiac anomalies.

She should be informed that the next step would be to organise a further detailed scan to look for other anomalies particularly cardiac. If there are no further abnormalities found, there is no additional risk of chromosomal abnormality. If there are further abnormalities or previous screening was high risk she should be offered an amniocentisis for fetal karyotyping.

She should be told that he ongoing care will involve am MDT including obstetricians, paediatricians and neonatal surgeons and she will have the opportunity to meet the team.

The woman should be given the opportunity to ask questions and she should be given a contact number of a named liaison midwife. All information given should be backed up with written information where possible detailing the nature of the defect, the nature of the surgery and the process of induction

b.A plan for deliver should be well documented in the notes.

Delivery should be in a tertiary centre with neo-natal surgical and neo-natal intensive care facilities.

Mode of delivery does not affect outcome and in the absence of obstetric indications she should aim for vaginal delivery.

She should be given a date for IOL at 37 weeks. The paediatricians and surgeons should be informed of this date and should be called to the delivery room when delivery is imminent. There are no associated increased obstetric risks associated with gastroschisis per se but and experienced obstetrician should be on hand to facilitate deliver.

 Once in active labour venous access should be secured and FBC and group and safe sent. This is because of the increased inherent risk of operative vaginal delivery associated with induced labour at Labour at 37 weeks.

She should have one to one care throughout labour by an experienced midwife and she should be monitored continuously throughout labour because fetal heart rate abnormalities are well documented.

The protruding bowel should be handled carefully during delivery. Great care should be taken when clamping the cord that bowel is not clamped in error. The baby should be placed straight into a warming bag with warmed isotonic saline solution insitu. The baby should be promptly handed to the paediatric team who will expedite surgical repair. 

Posted by ani S.

a. The patient should be counselled in a quiet condusive environment, with presence of partner if she wishes. There would be emotional upset and counselling should be in a caring and empathetic manner. The nature of the defect should be explained in lay man terms, informing that there is a defect in the baby's abdomen causing the gut contents to protrude into the sac of fluid surrounding the baby.  She would require further detailed scan as well as fetal echocardiograph to rule out any associated malformation. She should be reassured that usually (

b. The plan for delivery should be documented in the notes. Delivery should ideally be in a tertiary center with expertise for neonatal resuscitaion and surgery. The mulidisciplinary team  involved in her care should be notified when she is in labour. If she has premature labour, the corticosteroids for fetal lung maturation should be given. Vaginal delivery anticipated unless due to obstetric indication. Continous fetal monitoring intrapartum. Careful handling of the intestinal contents during delivery. Neonatologist should attend delivery. Sterile plastic bags should be used to wrap the contents of the bowel and measures to prevent hypothermia and fluid loss is taken.

Part A which got lost in transmission Posted by ani S.

a. The patient should be counselled in a quiet condusive environment, with presence of partner if she wishes. There would be emotional upset and counselling should be in a caring and emphatetic manner. The nature of the defect should be explained in lay man terms, informing that there is a defect in the baby's abdomen causing the gut contents to protrude into the sac of fluid surrounding the baby. She would require further detailed scan as well as fetal echocardiography to rule out any associated malformation. She should be reassured that usually, it is not associated with chromosomal anomalies (less than 1%), unlike exomphalos. If the defect is isolated, the karyotyping is not recommended. The risk and benefit of amnoicentesis needs to be weighed as it can cause fetal loss of 1%. The prognosis is good with 80% survival after corrective procedure.A multidisciplinary team will be involved in her care consisting of an obstetrician, fetal medicine specialist, neonatologist, paediartic surgeon and midwife. A referral to a tertiary center would be ideal. During the course of pregnancy, the complications that can arise are fetal growth restriction, polyhydramnios, bowel torsion and sudden intrauterine fetal demise. Hence, serial monitoring with ultrasound scans for fetal growth, amniotic fluid volume, bowel morphology is done and doppler if indicated. As there is a risk of preterm labour, prophylactic steroids for fetal lung maturation is given. The timing, mode and place of delivery need to be discussed and documented in the notes. Ideally, delivery should occur at a tertiary centre with necessary expertise for neonatal resuscitation and operative intervention. Vaginal delivery is advocated unless due to obstetric indication, requiring C section. There is no role for routine induction of labour or early delivery unless there is evidence of fetal compromise. The couple need to be aware that operative procedure to correct the defect will take place early, within 12 hours of birth. They should be reassured that the condition has a low recurrence in subsequent pregnancies. Written infromation and leaflets including support group information is provided.

Essay 355 Posted by Chetna K.

Ans a) Considerable maternal anxiety is expected. Sympathetic and sensitive approach needed.

Patient should be counselled with her partner or any other family member.

Ultrasound findings are explained in a simple language.The fetus has the defect in the abdominal wall due to which the loops of small intestine lie outside abdomen and float freely in the amniotic fluid. Sometimes along with the bowel loops, liver, stomach,or colon can also be present.

The incidence is 1: 2,500 to 1:3,000. It can be associated with chromosomal anomalies rarely (in <1%) . It may be associated with other structural defects like diphragmatic hernia,cardiac defects or cleft palate. This can be ruled out by detail scan at tertiary hospital. 

Only if associated with other defects, karyotyping needs to be done to rule out chromosomal anomalies. She need to undergo amniocentesis for that. It is an invasive procedure and ther is risk of fetal loss of ~1% above the background risk. The results will take ~ 2weeks but if FISH method is used, results can be known in 48 hours.

Prognosis is good if not associated with other defects and survival rates are >80%.

She should be assured that the defect is correctable for which involvement of pediatric surgeon , neonatologist and anesthetist will be required . The couple will have an opportunity to meet them for the detail information regarding  surgery, pre and post operative care and complications and the duration of hospitalisation required. This will allow them to have preparations beforehand.

It is associated with fetal growth retardardation, excessive fluid around the baby and sometimes intrauterine death. Therefore serial growth scans will be required .

Baby needs to be delivered once mature i.e around 37-38  weeks due to risk of fetal death. Delivery will be planned in a tertiary hospital where facilities for pediatric surgery and neonatal care will be available. If she doesnt go in labor spontaneously by this time, induction of labor will be required. Cesarean section is not indicated for this condition but any other obstetric problem  may require this. During delivery, presence of neonatologist will be ensured and cautious bowel handling will be done. Baby will be shifted to neonatal intensive care unit immediately. Further care will be taken by pediatric team.

She should be assured that the recurrence risk is low (<1%).

Her scan findings and plan of care should be mentioned in her notes. 

Finally she should be given written information or  leaflets and contact numbers of support groups

Ans b) Delivery must be planned at a tertiary centre with facilities for pediatric surgery and neonatal post-operative care.

There is no indication for routine cesarean section and vaginal delivery should be planned. Cesarean section should be reserved only for obstetric indications. 

Induction of labour done at 37-38 weeks if patient doesnt go in spontaneous labor since there is risk of IUD in such cases. Method of induction depends on her previous obstetric history and her findings on admission .

Induction done preferably in morning hours when senior obstetrician can assess the progress and timely decision can be taken.

Neonatologist, neonatal care team and anesthetist should be informed regarding patient's admission and the delivery plans. Patient should be reviewed by them after admission.

1:1 midwife support is preferable.

Epidural analgesia is not contraindicated.

Continuous electronic fetal heart rate monitoring done due to risk of IUD.

Delivery should be attended by senior obstetrician.

Presence of neonatologist is ensured during delivery.

At delivery , gentle handling of bowel loops done and covered with sterile bag with warm saline in it and baby shifted to NICU immediately.

 

 

.

Gastrochisis Posted by Bindu R.

A]        The first step is to  explain   the  diagnosis  to the woman  in a  sympathetic and sensitive manner.She should be given  option of having her partner or  someone else with her  while explaining the diagnosis.She might initially refuse to accept it and  a skilled  counseller is necessary.Alarming the  woman about the abnormality   might   be  counterproductive  and the  woman might choose to have termination of pregnancy.

Explain   about the scan findings .Explain that this  is a  congenital fetal anomaly of the fetal abdominal  wall and that there is a paraumbilical defect usually on the  right side.Always explain in simple  english  which she can understand.This   abdominal defect is associated with  herniation of the   fetal  intestinal loops through the abdimnal wall defect    and floating free in the  amniotic cavity. Incidence is  1: 3000  deliveries.Around  10 %  of gastrochisis is associated with other structural anomalies.Not associated with  chromosomal anomaly if isolated defect .Can be associated with chromosomal  anomalieis if associated with other structural anomalies.Risk  of chromosomal anomaly is only 1 or less than 1 %.Associated with raised MSAFP.

Maternal risks involves polyhydramniosis and therefore maternal discomfort and early delivery.

Foetal risks include  IUGR and  preterm delivery and increased risk of unexplained  intrauterine death by term   and so close monitoring is needed.

Woman should be offered detailed anomaly scan from a tertiay care centre and she has to be followed up in a foetal medicine unit.

 3  possible scenarios  for her subsequent  management.First is  this  defect can be isolated  which   does not need any immediate active intervention except  for close foetal  growth   monitoring ,assesment of liquor volume  and  bowel appearence and   for early surgery  to correct the  paraumbilical defect after delivery.Second  scenario  is  gastrochisis associated with other  structural anomalies.If associated with major anomaly not compatabile for life then offer termination .It may be necessary to  refer the woman to a clinical genetist  for a syndromic diagnosis and for further counselling.Third scenario is if gastrochisis associated with   other structural anomalies  then offer her karyotyping   and if  associated with chromosomal anomaly  offer her termination.Karyotype is not usually  indicated unless other anomalies are present.

   She needs joint counselling with  neonatologist and paediatric surgeon  to discuss about the   plan of mangement for baby after delivery.She should be explained that  baby will need   surgery as soon as possible after delivery in view of   exposed bowel.Explain to her that the  prognosis is  good with 80 %  survival.

She can have vaginal delivery  .Plan her delivery by term,do not allow her to go post dated.Caesarean  only for obstetric reason.

Offer her written  explanation and  offer  address of other  support groups.

B]   This woman should be delivered in a  tertiary care centre  where all facilities for   baby after delivery is available.Neonatologist and   neonatal surgeon   and team   should be informed  when she comes in labour.They should be available  during the time of  delivery    for neonatal resucication if needed and  to  plan  further surgery  as soon as possible to replace  tjhe intestinal loops inside  and   correct the defect .She will   need continuous  CTG monitoring in labour.Aim for vaginal delivery.Delivery should be as gentle as possible .Avoid   handling the intestinal loops.

The couple  needs to be  counselled and reassured that    the   anomaly has very small chances of  recurrence in the  future pregnancy.

Needs appointment for  postnatal follow up and counselling.Advice on contraception and breast feeding .Offer  Rubella vaccination if not immunised.Advice  her on cervical screening as a routine.

 

Gastrochisis answer. Posted by Mythli B.

 

a)

The patient is preferably seen along with her partner or any other family member. An empathetic attitude and willingness to address their queries is necessary.

She is explained in simple words that gastrochisis is a condition the where there is a small defect in the abdominal wall of the foetus as a result of which the intestines come to lie outside the body, floating in the amniotic fluid around the foetus. It is a potentially correctable defect after birth, with a survival rate of 80% when there are no other associated abnormalities.

As about 10% of the foetuses may have associated chromosomal abnormalities, gastrochisis necessitates amniocentesis and karyotyping. Amniocentesis involves sampling the amniotic fluid and investigating the foetal cells for possible chromosomal abnormalities using the PCR (polymerase chain reaction) or the FISH (Fluorescent in-situ-hybridization) tests. Amniocentesis is associated with a 1% chance of procedure-induced miscarriage.

If the patient opts for termination of pregnancy, her wishes are respected and complied with.

She is explained that during pregnancy, the foetus may be at a risk of growth restriction and developing hydrops (Accumulation of fluid in the body cavities and skin). She may be at increased risk of polyhydramnios and its attended complications.

In the absence of development of hypertension or diabetes, she needs routine antenatal care. The fetus is assessed by serial scans evry3-4 weeks or earlier if necessary. Amniotic fluid, growth restriction or development of hydrops are looked for. There is no specific indication for early induction and patient is allowed to go into spontaneous labour.

As gastrochisis needs surgical correction post-delivery, she must deliver in center with facilities for paediatric surgery and neonatal Intensive care facilities. She is advised to have a consultation with the paediatric surgeon and the neonatologist. Patient information leaflets and support groups information must be shared.

Discussion and antenatal care plan are documented in the patient’s notes.

 

b)

Delivery must be in a consultant led unit and in a centre with facilities for paediatric surgery and ICU. Continuous fetal monitoring is necessary. The neonatologist, paediatric surgeon are informed. Patient may receive epidural analgesia if needed. Progress of labor is monitored and the second stage may be cut short with forceps or ventouse. The foetus is handled gently during delivery.

After the initial assessment, the baby is kept warm, hydrated and oxygenated. The protruding contents are placed in a sterile bag containing isotonic, warm solution and baby cared for. The decision for the timing of surgery rests with the pediatric surgeons.

Posted by BHAWANA  P.

I will counsel her with a sensitive approach as she may not be prepared for the diagnosis. Involvement of partner and other family members will be offered.She will be explained about the diagnosis in simple language that loops of bowel are outside the abdomen through abdominal wall defect. Isolated defects have good prognosis ( >80% survival).Detaliled scanning should be done to exclude other structural abnormalities. If other abnormalities are present, she will be offered karyotyping to rule out chromosomal abnormalities. ( abnormal karyotype <1%) As she is 20 weeks, amniocentesis will be discussed for karyotyping explaining risk of miscarriage 1-2 % and small risk of spontaneous rupture of memebranes and infection. She will be referred to fetal medicine specialist. Joint counselling with neonatologist and paediatric surgeon regading surgery and prognosis will be arranged. 

As foetus is at risk of intrauterine growth retardation, serial growth scans will be advised including doppler and liquor volume. She will be monitored more closely after 36 weeks because of risk of intrauterine death. She is also at risk of developing polyhydramnios and preterm labour and signs and symptoms will be explained to her to seek medical attention.Risk of recurrence in next pregnancy is low.Post- natal management including need for prolonged hospitalisation should be explained.

She should be supported throughout her pregnancy .Information leaflets and information for support groups will be provided. 

b)Her care should be transferred to a tertiary care unit with facilities for neonate and availability of paediatric surgeons at the time of delivery.Her management for delivery would be to aim for vaginal delivery  and caesarean section reserved for obstetric indications only.She will be allowed to progress till term though delivery may be induced after 37 weeks because of risk of Intauterine death.Continuous CTG monitoring in labour will be done. Anaesthesist should discuss regional anaesthesia and continuous support by midwife should be given.

Delivery will be conducted by experienced midwife/doctor in a gentle manner as bowels are exposed.Neonatologist shoud be present at the time of delivery. Baby will be delivered in a plastic bag containing antibiotics and electrolytes. Baby wll be admitted to special care unit and after  initial stabilisation, corrective surgery should be performed as  soon as possible.

essay 355 ans Posted by rimpi D.

a) The woman should be dealt with a sympathetic approach while counselling as this is associated with a significant emotional upset for her. she should be explained regarding the condition in a simple language that there is a defect in the abdominal wall and the baby's intestines are freely loating in the amniotic fluid. She should be informed that the prognosis is good with 80% survival with early neonatal surgical intervention.There is a possibility of other structural defect in the baby which is less than 10 % and can be usually  detected in ultrasound. In the absence of any other structural problems, the prognosis remains good.The chances of karyotype or genetic abnormality is less than 1% and so invasive testing like amnioscentesis is not recommended in the absence of any other structural defects.She should be explained that there is small possibility that baby may have poor growth and so she will need serial ultrasound growth scan to detect it early. there is also a chance of increased liquor aroun the baby which can be also monitored by serial scans.Ultrasound is also done to check for any detection of abnormality in the loops of intestine in all the scans.She will be monitored closely in the 3rd trimester and will need more number of hospital visits as the baby has a small chance of intrauterine death in 3rd trimester.She should be offered multidisciplinary team management with referral to neonatologist and pediatric surgeon.She is advised to deliver in a tertiary unit with immediate facility for neonatal surgery for improved prognosis of the baby.She should be explained that vaginal delivery is possible and no need for a planned cesarean sectionShe should be informed that this has very low risk of recurrence in subsequent pregnancies..After a non persuasive counselling, her attitude towards the baby and wishes should be respected . Termination of pregnancy is acceptable if she wishes that after the counselling session.All the verbal counselling should be documented and written leaflets should be provided.

b)She should be delivered in a tertiary centre with 24 hrs facility of pediatric surgical unit. Aim should be for vaginal delivery unless some obstetric indications for CS.There should be good communication between, obstetricians, neonatologists and pediatric surgical team.There should be a continuous professional support to the woman during the labor. Continuos  electronic fetal monitoring is recommended as higher chances of intrauterine death.Adequate pain relief with epidural analgesia should be offered.Neonatologist should be present at the time of birth. Delivery should be by senior obstretrician.Gentle handling of the bowel loops at delivery is utmost imprtant.The bowel loops should be covered with a plastic bag containing warm fluids and baby should be transferred to neonatal ICU imeediately. Early primary surgical closure should be arranged. Active management of 3rd stage of labor should be done.

Posted by Muthu M.
  1. The patient needs to be seen at the Consultant led clinic.  When I review the notes and scan findings, I need to explore whether gastroschisis was an isolated finding or any other abnormality noted.  And also make sure whether she had the combined at the 1st trimester and she was considered as low risk by nuchal translucency scan & serum screening.  If it is an isolated finding, I would reassure the patient.  Explain the scan findings and the condition (Ie) gastroschisis to the patient that the contents of abdominal cavity the baby is found outside, not covered with a sac or abdominal wall.  As it was the only abnormality we found, it has only less than 1% chance of being associated with any chromosomal abnormality.  The prognosis and the life span is more than 80% good.  I would explain to the patient that I would refer her to tertiary care center where there is facilities to meet the doctors in a combined clinic between Obstetrician (or fetal medicine conusultant) and Paediatric Neonatologist and Paediatric surgeon.  The paediatric surgeon’s would be able to explain to the patient about the need for operative intervention and when it would be done and success rate and whether baby would need one or more surgical intervention.  I would make sure that patient understands, paediatric surgeons would operate on the baby more or less straight way as soon as the baby is born.  I would explain to the patient that the deliver would be planned to have at the centre where paediatric surgeons available.  I would also counsel the patient that we would aim for vaginal delivery and there is no contraindication to have a vaginal delivery based on the findings of gastroschisis, unless vaginal delivery is contraindicated due to other Obstetric reasons.  I would also inform the patient about the risk of polyhydromnios, preterm delivery and intrauterine growth retardation.  I would arrange for her to have growth scans at 28, 32 and 36 weeks and subsequent follow-up at the antenatal clinic to review the patient.  I would provide her with written information about the condition.  Apart from this, she needs regular antennal care, (ie) needs blood pressure check, urineanalysis, fetal heart listen in during every antenatal visit.  She also needs Full Blood count check and Blood group and antibody screen at 28 weeks. 
  2. The delivery should be at a center where paediatric surgery facilities are available.  The main aim would be vaginal delivery unless there is any obstetric reasons to do caesarean section.  As there is polyhydromnios present, there is risk of threatened or preterm labour possible.  If necessary, may need to have steroid injections for fetal lung maturity.  On admission to labour ward in labour, the whole team should be alerted – the paediatrician and the paediatric surgeon.  The neonatologist should be present at the delivery.  The baby should be wrapped up special bag to avoid exposing abdominal contents at the delivery.  Otherwise the delivery would be treated as any other normal laboring women in labour.  In view of IUGR risk, continuous CTG monitoring would be done.
H H XXXX Posted by H H.

A sensitive and sympathetic approach in counseling this patient is needed as I am breaking bad news . Her baby has an abnormality. I should tell her not to blame her self and nothing that she has committed or omitted ,has led to this problem. I would give her time to come to term with her condition. I would explain what the abnormality include, there is a defect in the anterior abdominal wall as it failed to form,and through this defect which is usually on the right side of abdominal wall the viscera are coming out loose in the amniotic cavity. The good thing is that it is not usually associated with chromosomal defects as seen with omphalocele( defect at the umbilicus),and is compatible with life after correction. There is however risk of intestinal damage, intrauterine growth retardation and still birth.

I would explore her attitude toward an affected pregnancy. Should she opt for termination,I would explain that this would be by medical methods including giving oral pipestone followed by vaginal misoprestol. Would explain risks as bleeding and retained products that may need further surgical evacuation.Would explain duration of hospital stay and follow up.

Should she opt to continue with pregnancy ,I would tell her that she will be cared for in fetal medicine unit. Ultrasound scans every 2weeks for fetal growth ,amniotic fluid volume and umbilical Doppler flow. Should there be other fetal defects or multiple soft markers ,amniocenteses for varityping is done.

Timing of delivery should be in a multidisciplinary decision taking opinions of neonatologist,pediatric surgeon,fetal medicine specialist in cosideration. Maternal wishes are respected to mode of delivery.Steroids given should there be risk of preterm delivery. Aim for vaginal delivery,cesareanC/S for obstetric indication. Patient given written and diagrammatic information.

 

 

B) Aim for for vaginal delivery, C/S for obstetric indication.Place of birth in a tertiary centre with intensive care neonatal services(NICU) under consultant obstetrician, fetal medicine specialist, pediatric surgeon ,neonatologist and midwifery care. Patient given proper analgesia ,under anesthetist care. Continuous electronic fetal monitoring is given. Care in handling baby after delivery, intestine covered with sterile wet dressing or a spcial plastic bag. Surgical team ready and surgical correction done,this might need several sessions. Tissue expansion techniques to allow covering of intestine with the abdominal wall might be needed. Follow up of baby during neonatal a child life. . Woman told that recurrence of the condition is unlikely. Care to early detection of postpartum mental illness as post partum depression is considered.

 

Posted by Kim M.

I would explain to her that gastroschisis is loops of bowel within amniotic cavity and this puts her at risk of polyhydramniosand IUGR in pregnancy.  I would put her under consultant led care and  I would advise, once I had excluded other anomalies on scan that this is not associated with any chromosomal problems and she would not need an amniocentesis.  I would suggest serial growth scans for liquor, growth and bowel appearance to ensure peristalsis is taking place and to pick up any IUGR or polyhydramnios that she is at increased risk of.  I would also explain the need for closer monitoring towards her due date due to the increased risk of IUD near term and the low rate of recurrence in future pregnancies.  I would give her written information regarding gastroschisis, and book her an appointment to come back and discuss gastroschisis further once she had come to terms with the diagnosis and answer any questions she had at that time.  I would also ensure she had contact numbers for any further information she needs.  I would arrange a multidisciplinary meeting with the neonatal team and the surgeons.

I would plan to deliver her in a tertiary centre with involvement from the neonatal team.  I would discuss with the patient the option for induction following 37/40 due to the increased risk of IUD and take into account the patients wishes.  I would aim for a normal vaginal delivery and would have continuous CTG during labour.  I would advise careful handling of the bowel at delivery and close input from surgeons as surgical repair would be best done as soon as possible.  I would debrief the patient after her delivery and inform her of the signs of postnatal depression as she would be at increased risk of this due to her baby's condition and stay on NICU following surgery.

Ans 355 Posted by Ranu R.

a) Acknowledging her anxiety, the young lady is counselled in a sensitive and sympathetic manner. She is told that her baby has a defect in the abdominal wall at one side of the umbilicus. Some portion of baby’s gut escapes through this hole and floats in the fluid in mother’s womb. The mother is informed that overall survival in such babies is good, almost 90%. She is assured that multidisciplinary team will be involved in her care to optimise outcome. Joint counselling with paediatric surgeon/ neonatologist should be offered.

Non-judgemental sensitive enquiry is made regarding use of cocaine, vasoactive drugs like pseudoephedrine and smoking; as all of these are found to be associated with gastroschisis. If she is using any of these, detailed counselling is required to help her quit or at least reduce intake. Substance abuse is also associated with increased risk of pre-eclampsia, placental abruption and growth retardation. Liaison with social care professionals is required to ensure supportive and coordinated care during pregnancy.

Presence of other anomalies along with gastroschisis is uncommon [10-20%]. Fetal echocardiography is offered to detect any cardiac anomaly. In absence of other anomalies, karyotyping is not essential due to extremely low incidence of aneuploidy.

The pregnant lady is informed about increased incidence of intrauterine growth restriction, preterm labour and intrauterine death near term. Gastroschisis is also associated with polyhydramnios. To detect all these complications, she will require frequent monitoring and surveillance. Serial scans to assess fetal growth, liquor volume, degree of bowel dilatation and bowel wall thickness are offered. Sonographic evidence of small bowel and mural thickening correlates with intestinal damage and poor clinical outcome. She should be closely monitored for fetal wellbeing by weekly/ biweekly biophysical profile and CTG from about 32 weeks onwards as there is increased risk of unexplained intra-uterine death.

Timing of her delivery will be determined by the severity of bowel involvement and coexisting features like polyhydramnios. Senior obstetricians and neonatologists are involved in the decision to balance morbidities of preterm delivery and impending intrauterine fetal death.

She is also informed that baby will require surgery shortly after birth. Though aim is primary closure, staged repair may be necessary. The baby will be in intensive care nursery for several weeks before intestines work well enough to allow oral feeding and subsequent discharge home.

She is informed that there is very low risk of recurrence; but exposure to vasoactive substances should be avoided in subsequent pregnancies.

Written information, preferably with diagrams and support groups are provided.

If she chooses to terminate the pregnancy, information is given regarding mid-trimester medical termination.

 

 

b) The delivery of this patient should be planned well ahead and documented in her notes, as there is increased chance of preterm labour. She should be delivered in a tertiary care centre in coordination with neonatal team including neonatologist, paediatric surgeon and paediatric anaesthetist. In absence of any complications or comorbidities, delivery at 37-38 weeks is acceptable. Presence of gastroschisis alone is not a contraindication to vaginal delivery and should be aimed for. However, if there is a large defect with possible liver involvement, elective Caesarean section may be preferable to reduce avulsion injury to the liver.

During labour, continuous CTG monitoring is done to ensure fetal well being. The mother may require higher doses of analgesics if she is addicted to substance abuse.

Goal of delivery should be to minimise trauma to exposed bowels by minimal handling. The baby is handed over to the paediatric team immediately after birth as arrangement for surgery should be made urgently.

The patient is offered active management of third stage of labour as associated polyhydramnios may cause uterine atony and subsequent post partum haemorrhage. Psychological support is provided as the baby would be separated from the mother in the immediate post partum period. 

Posted by Katy V.

 

a) Abnormalities identified at anomaly scans are associated with significant parental anxiety and distress, particularly as many couples do not fully understand the role of the scan as a screening test. It is therefore important that all information is given in a sensitive manner, in language that they will understand in a private environment. They are unlikely to remember everything told to them and thus written information, details of support groups and a contact telephone number in case of further questions should also be provided. If decisions are being made regarding further management or termination of pregnancy (TOP) these should be deferred until a follow up appointment in 1-2 days.

It should be explained that gastroschisis is where there is a small hole (usually less than 4cm) in the abdominal wall, with loops of bowel protruding through. The bowel is exposed to the amniotic fluid and can be damaged during pregnancy, gastroschisis is also associated with intrauterine growth restriction (IUGR) and alterations in the amount of amniotic fluid (both oligo- and polyhydramnios). In the majority, the prognosis good, however, 1:10 babies will die in utero or postnatally. It is usually an isolated finding and is not associated with any increase in chromosomal abnormalities and thus karyotyping is not indicated. They should be reassured that this also means recurrence rates are extremely low, and in fact gastroschisis is rare in women over the age of 25.

Management of the pregnancy and delivery should then be discussed. Thus they need to be aware that referral will be made to a fetal medicine centre for a detailed structural scan and to the paediatric surgeons. Additionally fetal growth and liquor will be monitored throughout pregnancy with regular scans. As the baby will need extra care immediately after birth and surgery as soon as possible (although this can be delayed 7-10 days if the baby is not well enough), delivery should occur in a centre with appropriate NICU facilities and paediatric surgical expertise. It is ideal if delivery can be planned and, as caesarian section (CS) is not indicated for gastroschisis alone, induction of labour (IOL) at 37 weeks is usually recommended. This has the additional benefit of reducing the incidence of late still births. Usually babies recover well from surgery, but there can be a delay in return of bowel function and it will require antibiotics and feeding support. They should therefore envisage a hospital stay of at least a few weeks but potentially longer. Referrals to the neonatal medical and surgical teams should be made to allow the couple to discuss these issues further and for the teams to plan appropriate management.

TOP is an option, however at 20 plus weeks this will be a traumatic experience for the woman and in view of the good prognosis would not be chosen by many couples in the absence of any other abnormalities. However, should they wish to discuss this, information should be provided in a non-judgmental manner.

 

b) A management plan for labour and delivery should be documented in the antenatal notes. In the absence of other obstetric indications for CS, IOL should be performed at 37 weeks after ensuring availability of a NICU cot. If the woman is admitted in spontaneous labour prior to this, both NICU and the paediatric team should be informed on admission. Continuous electronic fetal monitoring should be performed throughout labour/delivery, however, there are no contraindications to any form of analgesia including epidural/spinal, nor to procedures such as fetal blood sampling or instrumental delivery. It is important to minimize handling of the herniated bowel and thus this should be covered immediately after delivery with moist dressings. A paediatrician should be present at delivery as there is an increased risk of respiratory difficulties and a nasogastric tube will need to be placed. Should delivery earlier than 35 weeks be required or a CS performed before 39 weeks, corticosteroids should be administered antenatally as per current guidelines.

It should be remembered that the parents are likely to be experiencing considerable anxiety about the well being of their baby and thus every effort should be made to reassure them and normalize the experience. Additionally, they should be able to see, and hopefully, hold the baby as soon as possible after delivery.

answer 355 Posted by Nabila A.

Counselling should be done in conjunction with the neonatologist/paediatric surgeon.

The woman should be told that gastroschisis is due to a developmental defect in the abdominal wall through which the bowel loops come out and lying free in the amniotic cavity which can be repaired postnatally.It occurs in 1 in 3000 live births with an equal sex ratio.Its precise aetiology is not known... Recent studies show an association with ingestion of aspirin

It is associated in <1% with other structural abnormalities like  bowel stenosis/atresia and less commonly with cleft palate and diaphragmatic hernia  so a detailed sonographic search including for heart defects by a skilled sonologist be done.

 

The risk of chromosomal abnormalities is <1% so karyotype is not indicatedHowever risk of chromosomal anomalies increases if it is associated with multiple stuctural anomalies.Maternal risks  are few ..due to polyhydramnios ,consequently abdominal discomfort as well as the risk of preterm labour .

Fetal risks would be consequences of exposure of bowel loops to the amniotic fluid which can damage the bowel serosa.Bowel torsion or obstruction can occur leading to atretic segments which will be difficult to reduce or repair  during surgery.

Oligohydramnios can be associated with fetal growth restriction due to uteroplacental insufficiency.Polyhydramnios can also occur ..it is the only sonographic appearance associated with bowel complications rather than the bowel appearance.

Continuous surveillance of the fetus will be required for growth,liquor and bowel appearance.No need to deliver prematurely, no evidence that reducing the exposure to amniotic fluid will improve the outcome.Term delivry at 37 weeks  allows earlier and definitive closure of the defect

There is an  increased risk of unexplained intrauterine death near term so close monitoring neededespecially after 34 weeks either due to fetal growth restriction or umbilical cord compression.No need to deliver prematurely.

There is high chance of good outcome with >80% survival and a primary closure tion is rate of 50 -80% .However prolonged  is  hospitalization is required.

Recurrence risk is very low. Mortality rate IS BETWEEN 3-10% due to prematurity ,intestinal ischemia or necrosis or late sepsis or effects of other associated abnormalities.

Delivery should be in a tertiary referral centre equipped with appropriate facilities and staff for neonatal surgery.Plans discussed with the neonatal surgeons and  documented.Surveillance for fetal compromise needed in the third trimester due to increase risk of unexplained intrauterine death.Continuous electronic fetal heart monitoring done  during labour

Mode of delivery doesn’t affect the outcome.Vaginal delivery should be aimed  at term in the absence of other indications.

 

Handle bowel carefully  and place the contents in sterile plastic bag with or without warm isotonic solutions.Good neonatal care and primary closure will reduce the morbidity.

Posted by Adil H.

 

 

A healthy 23 year old woman attends for her anomaly scan at 20 weeks gestation. The fetus is found to have gastroschisis. (a) How would you counsel her? [14 marks] (b) Discuss your plans for delivery and intra-partum care [6 marks].

 

a)  She should be encouraged to bring her partner along . It will be explained after carrying out the necessary introduction, that the reason you have called them is that the baby is suffering from a structural defect, and the abdominal wall is not made fully. This requires a  sensitive, approach, the disclosure should be made in a quite un interrupted room, the condition should be explained along with pictorial help if possible or to make the diagram of the defect if possible information leaflets should be arranged as well.

The cause of abdominal wall defect which is autosomal recessive , may be sporadic needs to be explained and referral to genetic specialist may be undertaken.

 

 

It must be told that there is only 1% chance of associated congenital anamolies the survival rate after the corrective surgery is more the 80%- 90 % with modern techniques.

 

She will be offered prenatal diagnosis to rule out chromosomal anamolies which are rarely associated with this condition. In addition a detailed ultrasound will be carried out to rule out other structural defects. Amniocentesis is associated with a 1% rate of fetal loss. In the absence of other anamolies and chromosomal defects the prognosis after surgery is excellent.

 

They may want to discuss termination of pregnancy for which they can be guided.

 

The importance of understanding the need for frequent visits to the hospital for fetal suvaillance and , to see the paediatric surgeon. Referral to the specialist fetomaternal unit may be required. Practical arrangements which may involve travelling long distance and additional costs will be discussed.

 

Delivery can be carried out at term both vaginally and by elective caesarean section where appropriate expertise is available to handle such babies.

 

Usually the success of surgery depends upon the size of the defect, and the size of abdominal cavity if it is small then it may take longer time to grow and accommodate the herniated abdominal contents.

If small it is associated with good prognosis if large than an interval procedure may be required.

 

Further detailed information will be given by the paediatric surgical consultant.

 

 

 

b) The delivery will be vaginally or  elective caesarean section to avoid damage to the abdominal viscera,  in a specialist fetomaternal unit.

Where facilities are available will perform continous electronic fetal monitoring delivery to be performed by senior obstetrician, ensure gentle handling and covering the babys lower body in sterile saline solution , special bags are available these help to maintain temperature and avoid damage to the exposed intestines and abdominal contents. Baby will be cared for in the special baby care unit. Neonatologist experienced handle such babies would be called to attend the delivery.

In case of vaginal delivery a low threshold for caesarean section will be undertaken.

Surgery will be contemplated as soon as advised by the paediatric surgical team. Usually with in 12 -24 hours at term . 

Essay 335 answer Posted by Patricia L.

  (a)      Counseling should take place in a private place with her partner or family members informing regarding the scan findings. Diagrams may help to aid understanding of a defect in the anterior abdominal wall thereby exposing the bowels into the amniotic cavity. Care should be emphasized on using simple language. Explanation that this is a congenital defect and is not a lethal abnormality. Other associated abnormalities should be looked for prior to this counseling session and she should be reassured that in isolation the outcome for gastroschisis is good >80% . Reassure her that this is by no means her fault. Although karyotyping is not usually needed unless associated with other anomalies, she may be offered second opinion with a fetal maternal specialist which may advice her further.

       She will require multidisciplinary team management comprising of consultant fetal maternal specialist, obstetrician, neonatologist, paediatric surgeon, specialist nurse and counselor. She may be at risk of preterm delivery due to increased liquor volume (polyhydramnios).

Her options may be of terminating pregnancy or staying committed to her pregnancy. Termination of pregnancy would require possibility of fetocide if after 24 weeks, use of an anti-progesterone to withdraw progesterone support during pregnancy, followed by a prostaglandin 24-48 hours later. She must be made aware of the small risk of retained placenta requiring surgical evacuation. Choice of analgesia should be offered either epidural or parenteral opiodes. She should be given written information , given time and facility of a counsellor regarding this information of termination of pregnancy.

However should she choose to stay committed to her pregnancy, a plan on further pregnancy management is to be discussed as there is a risk of preterm delivery, polyhydramnios and maternal symptoms related to polyhydramnios, and unexplained uterine death. She will require serial growth scans, scan for liquor volume and bowel appearance. Delivery would be at a tertiary centre with neonatology, peadiatric surgeon and neonatal intensive care facility. Induction of labour and caesarean section are only for obstetric indications and vaginal delivery should be encouraged in the absence of contraindications. Surgical repair for the baby will rake place following delivery with good results in most cases.

Appropriate written information should be given to her regarding what has been explained, offer counselor facility and websites where more information may be given. 

Documentation and communication with local GP and midwife.

 

(b) Multidisciplinary management comprising of consultant obstetrician, fetal maternal specialist, consultant anesthetist, neonatologist, paediatric surgeon, and specialist nurse in tertiary center with neonatal intensive care facility. She should be aware of the risk of preterm delivery hence told regarding symptoms such as contractions, vague pains and leaking and to attend immediately to the hospital in such event. Antenatal corticosteroids may be required in this case.

     Vaginal delivery should be offered unless there is obstetric indications for caesarean section, operative vaginal delivery and or induction of labour. Adequate analgesia should be offered either in a form of epidural or parenteral opiodes. Continuous fetal heart monitoring intrapartum and one to one midwife care.

Neonatologist should be made aware when the patient presents in labour and be present upon delivery, care in handling the bowels during delivery and resuscitation should be as guided by the neonatologist.

She should be given support during the puerperium and advice regarding breastfeeding - storage of expressed breast milk according to the condition of her baby by a lactation counselor.

Debriefing should be given following delivery and she should be reassured that recurrence rate for such an anomaly is very low.

Plan for future pregnancy and contraceptive advice should be offered.

 

 

 

 

Holly Posted by holly L.

 

A)Prior to the ultrasound she would be made aware regarding the nature of the anomaly scan; ie to detect any fetal defects. It should be remembered that if a defect was indeed noted it is likely to come as a shock to the patient so the diagnosis should be given in a sensitive manner. It would be explained to her that a gastroschis had been noted and this diagnosis would be explained in simple terminology ie that there is a defect in the fetal abdominal wall with a protrusion of free floating bowel loops through this defect into the amniotic fluid. She would be counselled that it is not an indication for termination and would be reasurred that the prognosis is good with a 90% survival rate. The baby will need surgery following delivery to mend the defect with very little chance of resulting bowel dysfunction and will need to stay on NICU for a short period of time in order to recover.  It would be explained that this anomaly is unlikely to have any associated defects or be related to any syndrome. If all other structures on the anomly U/S were normal she should be reassured. If other anomalies are noted she should be offered invasive testing such as amniocentesis. She should be advised that although the exact cause is unknown, the recurrence of gastroschisis in a subsequent delivery is low and tends to affect younger mothers (<25 years).

She would be advised that her antenatal care would involve more hospital visits. As gastroshisis is associated with IUGR she will need serial growth scans throughout pregnancy at 28, 34 and 36 weeks. Her care would involve a MDT including obstetricians, midwives, paediatricians and neonatal surgeons. A normal vaginal delivery would be advocated and a c/section reserved for any obstetric complications. There is an increased risk of still birth at term therefore induction of labour could be considered at 39 weeks.

A follow up appointment would be arranged for the patient in the fetal medical unit and written information/leaflets on the condition could be given to the patient as well as support group contact details.

B) The aim would be for a vaginal delivery on labour ward in a unit that has access to neonatal surgical expertise. A c/section would be reserved for any obstetric reason.  An induction of labour could be considered before 39 weeks as there is an increased risk of still birth at term. Furthermore an induction would make it easier to coordinate care with the paedatrians and neonatal surgeons if delivery was planned. A delivery plan should have already been discussed and agreed in the antenatal period and a copy be in the patients notes in case the she presented in labour prior to her induction date. If the delivery is prior to 39 weeks, cortiosteroids should be given to reduce the risk of fetal RDS and NEC.

Once in labour she should have a continuous CTG and her progress plotted on a partogram. There is no contraindication for any type of analgesia or for instrumental delivery.  At the birth the paediatricians should be present and there should be minimal handling of the herniated bowel. As the bowel is exposed, surgery would need to be carried as soon as possible. Following surgery there is no contraindication to breast feeding.

Gastrochiasis Posted by Samira  K.

a-I will inform the woman that your unborn baby has got something called gastrochiasis which is a defect usually at right side of belly button.Because of this defect its intestines are hanging outside its body.It is associated with other structural abnormalities in less than 10 in 100 so we will perform detailed Scan again after 2-3 Wks to make sure there are no other abnormalities.Rarely less than 1 in 100 it is associated with chromosomal abnormalities ,so it is not necessary to go for Testing as testing has its own risks which might be more than the risk of having any chromosomal abnormality.You definitely need more monitering for your baby as there is some risk of  baby not growing well or delivering prematurely or even dying especially after 37 wks of pregnancy.For this reason i am going to refer you to fetomaternal physician who will see you every 2 wks from 24 wks and will do growth scan every 2-3 wks and if baby is not growing or water around your baby is not enough then he will ask for more advanced Scan called dopplers for your babys blood vessels so that he can decide when to deliver your baby.We will make sure if you are going to deliver prematurely by taking secretions from your cervix and by doing vaginal scans every 2 wks .We might induce you at 37 wks to have a planned delivery and we will discuss with neonatologist to be there at delivery time and to  make special arrangement with neonatal surgeon to see the baby as soon as possible.I think you understand very well that you need to deliver in a hospital with facilities of neonatal surgery.You can deliver vaginally and we will monitor your baby continously with cardiotocography .You can take epidural if you want.If we observe any distress of your baby we will go for emergency c-Section.As soon as your baby will deliver the neonatology team is going to wrap the intestines of you baby with a special sterile plastic bag to protect from heat and fluid loss.the surgeon will decide to perform surgery as soon as possible or to keep under observation so that intestines will return to its position by itself.Baby might need to  be ventilated artificialy for 2-3 days and will need artificial feeding through veins until start oral feeding.It seems complicated but survival rate is usually more than 80% .I will let you to see  neonatologist surgeon who will explian you more.The recurrance of this condition in next pregnancy is very rare and if it is an isolated defect prognosis is good.We will give chance to woman to ask questions.will address her concerns and wishes will be respected.We can support her and give her information leaflets .

b-Delivery should be in a hospital with facilities of neonatal surgery.As there is risk of sudden fetal death after 37 wks we can induce her at 37 wks.mode of delivery will be vaginal and C-Section for obstetric indications.multidesiplinary approach with senior obstetrician,senior midwife,neonatologist and neonatology surgeon should be undertaken.She can take epidural once in labour and should be on continious fetal monitoring .Neonatologist should be alerted and should be present at the time of delivery.care should be taken at the time of delivery and Intestines should be wrapped as soon as possible in sterile plastic bag to prevent from heat and fluid loss.Surgery should be performed as soon as possible in order to have good outcome.During labour  she  should be encouraged and supported by the staff and her partner.

Please send 2 last questions Posted by H H.

Dear Sir, please send 2 last questions with modle answers, and any last minute hot topics, obliged

correction Posted by Samira  K.

Dear Dr Paul

Can you please correct my answer .I am still waiting

Thanks

Samira Posted by Farrukh G.

 

a-I will inform the woman that your unborn baby has got something called gastrochiasis which is a defect usually at right side of belly button.Because of this defect its intestines are hanging outside its body (1) .It is associated with other structural abnormalities in less than 10 in 100 so we will perform detailed Scan again after 2-3 Wks why wait 2-3 weeks? to make sure there are no other abnormalities.Rarely less than 1 in 100 it is associated with chromosomal abnormalities if isolated ,so it is not necessary to go for Testing which testing?? (1) as testing has its own risks which might be more than the risk of having any chromosomal abnormality.You definitely need more monitering for your baby as there is some risk of  baby not growing well or delivering prematurely or even dying especially after 37 wks of pregnancy (1) you are answering an exam question, not talking to the woman. Your answer reads poorly as a result .For this reason i am going to refer you to fetomaternal physician who will see you every 2 wks from 24 wks and will do growth scan every 2-3 wks and if baby is not growing or water around your baby is not enough then he will ask for more advanced Scan called dopplers for your babys blood vessels so that he can decide when to deliver your baby.We will make sure if you are going to deliver prematurely by taking secretions from your cervix and by doing vaginal scans every 2 wks  not necessary. We might how will she know if you will or will not? induce you at 37 wks to have a planned delivery and we will discuss with neonatologist to be there at delivery time and to  make special arrangement with neonatal surgeon to see the baby as soon as possible why should they not see her before? . I think you understand very well that you need to deliver in a hospital with facilities of neonatal surgery very poor style.You can deliver vaginally and we will monitor your baby continously with cardiotocography .You can take epidural if you want.If we observe any distress of your baby we will go for emergency c-Section.As soon as your baby will deliver the neonatology team is going to wrap the intestines of you baby with a special sterile plastic bag to protect from heat and fluid loss.the surgeon will decide to perform surgery as soon as possible or to keep under observation so that intestines will return to its position by itself.Baby might need to  be ventilated artificialy for 2-3 days and will need artificial feeding through veins until start oral feeding. It seems complicated what? The condition? Your care plan?? but survival rate is usually more than 80% (1) if isolated. I will let you to see  neonatologist surgeon (1) who will explian you more.The recurrance of this condition in next pregnancy is very rare and if it is an isolated defect prognosis is good.We will give chance to woman to ask questions.will address her concerns and wishes will be respected. We can support her and give her information leaflets (1) why have you changed your approach here? This is the correct approach.

b-Delivery should be in a hospital with facilities of neonatal surgery ? neonatologist.As there is risk of sudden fetal death after 37 wks we can induce her at 37 wks.mode of delivery will be vaginal (1) and C-Section for obstetric indications.multidesiplinary approach with senior obstetrician,senior midwife,neonatologist and neonatology surgeon should be undertaken what will you do?.She can take epidural once in labour and should be on continious fetal monitoring (1).Neonatologist should be alerted when? and should be present at the time of delivery.care should be taken at the time of delivery and Intestines should be wrapped as soon as possible in sterile plastic bag (1) to prevent from heat and fluid loss.Surgery should be performed as soon as possible in order to have good outcome.During labour  she  should be encouraged and supported by the staff and her partner.

Answer Posted by Farrukh G.

A good answer should include

(a)

  • Explain nature of the abnormality (1 mark)
  • Explain need for detailed scan to exclude other anomalies (10% risk) (1 mark)
  • If isolated, karyotype not indicated (1 mark)
  • Explain prognosis. Dependent on presence / absence of other anomalies, viscera involved (worse if liver involved) (1 mark)
  • Explain risk of pre-term labour, IUGR, bowel compromise and late IUD (2 marks)
  • Explain risk of long-term feeding problems and bowel dysfunction (1 mark)
  • Baby will require surgery shortly after birth (1 mark)
  • May consider TOP especially if other defects are identified or abnormal karyotype (1 mark)
  • Explain need for fetal surveillance in fetal medicine centre (1 mark)
  • Need IOL ~ 37 weeks (1 mark)
  • Provide opportunity to meet with neonatal / paediatric surgical team (1 mark)
  • Provide written information and further appointment (1 mark)

(b)

  • Elective delivery should be planned in tertiary centre (1 mark)
  • Precise timing of IOL to take account of availability of neonatal and paediatric surgery facilities (1 mark)
  • Aim for vaginal delivery, CS for obstetric indications (1 mark)
  • Inform neonatal / paediatric surgical team when woman presents in labour or for IOL (1 mark)
  • Continuous monitoring in labour (1 mark)
  • Place abdominal contents in sterile plastic bag after delivery (1 mark)