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Essay 371: congenital anomaly

Essay 371: congenital anomaly Posted by Farrukh G.

 

A healthy 22 year old woman attends the antenatal clinic at 20 weeks gestation following an anomaly scan which found that the fetus has gastroschisis. Discuss your counseling and plan for managing her pregnancy [20 marks].

Posted by Anagha W.

I will explain the ultrasound findings that there is a defect in the abdominal wall which can be associated with the bowels lying freely outside. She should be given the information in a sensitive way as it would understandably be upsetting. I would explain to her that there is a possibility of presence of other abnormalities in addition to gastroschisis. Though not always, cardiac anomalies may coexist and hence she should be referred to a tertiary unit for counseling by a foetal medicine specialist and detailed scanning including cardiac scan by an expert.  I would explain to her that if there is isolated gastroschisis, the risk of chromosomal or genetic abnormality is low (less than 1 %) and karyotyping is generally not needed.  She should be given appropriate verbal and written information. After tertiary referral and detailed ultrasound scanning, the parents should have an opportunity to meet and discuss possible treatment options including surgical interventions with the neonatologist and neonatal surgical team. The need for early neonatal surgery, ideally within 12 hours, should be discussed. The prognosis after early surgical intervention is good with a survival rate of more than 80 %.

Gastroschisis is associated with higher risk of intrauterine foetal growth restriction and polyhydramnios. So antenatally she will require serial ultrasound scans for foetal growth and liquor volume. She will also require close monitoring in the third trimester as there is a risk of intrauterine death. If preterm delivery is anticipated, then antenatal corticosteroids should be administered for foetal lung maturation. As early neonatal surgery may be required, delivery should be planned in a unit with such surgical support. Hence timing and place of delivery should be discussed with the neonatal team. Plan for vaginal delivery should be made. Caesarean section may be needed if there are obstetric indications. The bowels should be protected during and after delivery to avoid inadvertent bowel injury. Experienced neonatologist should be present at the time of delivery as neonatal resuscitation may be required. Breastfeeding should be encouraged. I would explain to the parents that risk of recurrence in future pregnancies is very low. Referral to a genetic counselor should be arranged if there are associated chromosomal or genetic factors for advise on recurrence.

assay371 Posted by huaida A.

Counselling of this woman should be in sensitive  way , asupportive   personell should be available  .

I would inform her that this is a defect  in the anterior abdominal wall with  bowels floating freely in the amniotic sac . Rarely  the liver may also found  out side the abdominal cavity .I would inform her it may be associated with other congenital defects so should be reffered to a tertiary centre  for detailed anamoly scan .  If no associated anamoly   the risk of chromosomal abnormalities will be  low and hence no need for chromosomal analysis , how ever in presence of other anamolies specially cardiac anamoly  , there is a risk of associated  chromosomal abnormalities  in 10 % of the cases . An appointment with neonatologist and neonatal surgeon should be arranged  to discuss with the woman the prognosis and to explain to her that  the neonate would  need special handling after delivery ( bowel should put in sterile bag ) as well as a need for  surgery   after delivery . I would inform her that the fetus is at risk of intra uterine  growth restriction  so a serial growth scan would be needed .Would form her the the mode of delivery would be  vaginally  unless C/S is  indicated be obstetrical reasons.Her delivery would be attended by aneonatoligist.I would told her that the risk of recurrence in subsequent pregnancies would be low in absence of chromosomal abnormalities . All the discussion should be documented in the woman notes .She should provided with information leaflet .

essay congenital anomaly gastroschisis. Posted by MONA V.

 

Essay Fetal anomaly

The  woman should  be told of the finding in a sensitive manner . The exact nature of the anomaly is explained that it is a defect in the anterior abdominal wall next to the umbilicus and intestines float in amniotic fluid. She is offered support ,presence of partner or midwife.    She should be told about need for a second detailed scan to confirm the diagnosis  and look for any other anomalies like cardiac defects.

Karyotpe is not  offered routinely as associated chromosomal defects are less than 1%. If there are associated anomalies karyotype should be offered.  She is told that the outcome of baby is generally good  with 9 out of 10 babies surviving.  There may be fetal growth restriction, prematurity , bowel compromise  and small risk of intrauterine death. There may be long term feeding and bowel problems for the baby as it grows  and support is important at home.  After delivery baby would need surgery for correction of defect.

It is important to know her  attitude towards the pregnancy . She may choose termination of pregnancy and she should be given support.

  If she continues pregnancy  offer her serial growth scans as risk of fetal growth restriction in fetal medicine centre. Offer antenatal meeting with multidisciplinary team  comprising neonatologist ,paediatric surgeon team for best outcome. There should be a clear written plan for timing place and mode of delivery.

 She is given written information and contact of support groups like gastroschisis.co.uk, GEEPS.

Delivery planned in tertiary centre with neonatal /paediatric surgeon availability .

Plan  delivery by 37- 38  weeks as there is risk of stillbirth and  serious bowel damage  after discussion with mother ,neonatalologist.   Inform neonatal team when she comes in labour or admitted for induction of labour.    Aim for vaginal delivery with caesarean for obstetric reasons. Continous fetal monitoring in labour is recommended. 

After delivery the abdominal contents placed in sterile bag to avoid contamination and infection. Primary or  staged surgical repair performed depending on size of defect  and condition of the baby.  Breast feed encouraged as per advise from neonatal team . Explain that recurrence is very rare. 

Posted by Nana  B.

 

I will see her together with a fetal medicine specialist, specialist midwife, a neonatologist and a paediatric surgeon.  I will ensure uninterrupted privacy, and the presence of a close acquaintance of her choice.
I will take a brief history and review her hospital records to exclude a high risk aneuploidy screening result, consanguinity, and a history of genetic disorders on the partner or patient’s side of the family, as these may determine the need for further investigations.
I will exclude any previous recurrent pregnancy complications eg obstetric cholestasis, precclampsia and GDM as this will necessitate surveillance or screening for recurrence. I will check past modes of delivery  and birth complications as these will influence the best advise I give on mode of delivery.
I will explain that gastroschisis is a congenital defect in the anterior abdominal wall, that allows some contents of the abdomen, usually bowel, without peritoneal  covering, to protrude into the amniotic cavity. I will explain that this is usually a sporadic, unexplained, isolated defect.   I will explain that in the absence of any other abnormality, there is a good outcome for the baby following specialized antenatal care and planned postnatal surgery  to repair the defect for the baby, and that no long-term health problems are expected following good recovery from surgery. I will explain that  she needs to receive largely hospital based antenatal care with delivery in a regional center for postnatal surgery.
I will offer her a repeat detailed anomaly scan, by a fetal medicine specialist to confirm the defect, and explore for other anomalies. 
I will provide written information on gastroschisis as well as the website of a gastroschisis support group. I will document a detailed plan of care and write to her GP to update them. 
If she opts for TOP, I will ensure she receives additional counseling by a specialist counselor, before proceeding with termination, as the anomaly carries a good outcome with good management.
Most women will not terminate the pregnancy, and I will arrange serial growth scans 4 weekly from 24 weeks, by a fetal medicine specialist as the defect may interfere with accurate measurements of the fetal abdomen. In the presence of growth restriction, I will monitor growth 2 weekly and initiate umbilical artery dopplers and amniotic fluid assessment  1-2 weekly depending on severity of growth restriction. I will plan delivery in the presence of abnormal umbilical artery dopplers or static growth over a two  week period, following steroid prophylaxis.
I will liaise with the regional fetal medicine center with level 3 neonatal care, to arrange for shared care and delivery at the center.
I will review her at 36 weeks and agree and document timing and mode of delivery. In the absence of complications I will advise vaginal delivery, in the absence of contraindications.  
I will plan elective caesarean or induction of labour at 39weeks gestation to prevent complications of prematurity and also to facilitate optimal team planning towards neonatal care and surgery.
I will advise her that following delivery the baby would be wrapped in a special plastic bag to prevent infections, drying and dehydration.
 
I will explain that the baby will stay in the neonatal unit prior to and for a few days following surgery .
 I will explain that she can breastfeed the baby following recovery from surgery
 
Answer 371 Posted by uzma sultana M.

The diagnosis must be told the patient very sensitively .   this might cause anxiety and emotional upset in the patient .  tell her that the bowel contents are outside the abdominal cavity in the amniotic  fluid .   the prognosis is bad if the liver is out side .  Tell the patient  that this defect is not due to her . This might be associated with other structure abnormalities such as cardiac, skeletal and GIT .  and also associated with chromosomal anamolies . There is increased risk of premature labour , IUGR, bowel dysfunction and late IUD .  This patient needs to be referred to a tertiary center for detail anamoly scan by an expert sonologist  to pick other structural abnormalities .  if it is associated with many structural abnormalities then offer termination of pregnancy .   if this is not associated with chromosomal anamoly no need for karyotyping .  Tell the patient if it is an isolated abnormality the prognosis is good after correction .  about 75 % survive after correcting the defect .   There might be feeding problem after the birth and bowel compromise until correction .  give contact number of the support group .    A multidisciplinary approach involving the pedeatric surgeon and pediatric team  is needed .  an appointment should be arranged with them to discuss about the issue .  plan should be made and documented in her notes  about  the timing , mode and place of delivery .  serial growth assessment  scan and bowel assessment should be done every 2-4 weeks from 24 weeks onwards .  doppler must be done for fetal well being .  Third trimester must be monitored closely as there is risk of  late IUD .  The patient may need to go for IOL after 37 weeks of gestation to prevent late IUD .  if she goes in labour before or at 34 weeks then prophylactic corticosteroides are needed for lung maturation .  she should be delivered vaginally .   ceaserean section for obstretic reasons only .  During intrapartum period neonatologist must be present .  anaesthetist much provide adequate pain relief .  aseptic precaution must be used .  hygiene must be maintained .  continous CTG to monitor the fetus .  after delivery place the bowels in sterile bag .  breast feeding is encouraged . The baby is assessed by the pedeatric surgeon for his general condition and the amount of defect and surgery plann ed  accordingly .  preferably with in 12 hrs and post operatively transfered to nicu .  post natal advice is given on contraception .  and prepregnancy counselling for the next pregnancy .  tell her that the recurrance risk is low .  provide information leaflet and further appointment .

Ans 371 Posted by Gopal H.

I will have a supportive and sensitive approach towards this women, will make sure she is accompanied with partner or friend or family member before discussing further. I will explain the diagnosis, that its a deficiency in formation of anterior abdominal wall, so the contents of abdomen like bowel and stomach etc will be found outside the body. This condition is unlikely to be accompanied with chromosomal abnormality (<1%) so not much information from karyotyping, She will be referred to a specialised fetal medicine unit with paediatric surgery fecility, as it can be fixed by surgery, most of the time after birth. During antenatal period she might have more scans to monitor for fetal growth as there is risk of fetal growth restriction, premature labour. After birth baby might be assessd for suitability of surgery either in one step or subsequent surgery to create space inside her abdomen in stepwise fashion. she might develop feeding problems after birth. She will have to wait for the multidisiplinary team (Neonatologists, Obstetric team, paediatric surgeons) to decide for a plan for place of birth and shared care until then. timing of delivery might be too soon to decide , but will try to acheive atleast 36 weeks mostly. I will also tell her that its a sporadic condition and recurrence risk is absolete. I will provide writtern information about this condition and also provide contacts of support groups of gastrochesis society. I will also be happy to see her in my clinic if she wishes to discuss further after her fetal medicine referral, so she can contact my secretary for arranging appointment ( will be provided with a contact number).

I would refer her to regional fetal medicine unit for detailed scan and further management plan of combined care, as most of these women are still followed in their respective centres, while deliver in teritary centre with paediatric surgery facility. She will need growth scans and monitoring of the defect every two weeks from 24 weeks. we will work along with the neonatology team in referral centre. I will write referral letter to the regional centre and also inform her General practiotioner and community midwife about the plan. I will coalease with regional centres about planning her antenatal visits, so she doesnot have to repeat her checks. a effective communication with less hastle for the women with be the aim.

 

 

essay 371 Posted by Gajendran K.

i will explain to her in a sensitive and tactful manner regarding the diagnosis of gastrochisis whereby it means there is a defect at the abdominal wall and this has caused the fetal bowels to lie freely in the abdominal cavity. I will inform  her that i will have to send her for another scan by a fetomaternal specialist for a detailed morphology scan to look for any other anomalies .Anomalies such as cardiac lesions when associated with gastrochisis increased risk of chormosomal abnormalities up to 10% and hence a an amniocentesis may be needed. However if there are no other anomalies risk of chromosomal abnormalities are just about 1% .I will also co-manage early with a multidisciplinary team aprroach comprising of neonatal surgeon , neonatalogist and a specialist mid wife. During her antenatal followups , serial scans should be done for fetal biometry to look for evidence of IUGR and liqour volume for polyhydroamnios and scans for bowel morphology. I will also inform her that there is an increase incidence of sudden intrauterine death espeically in the third trimester . I will also inform her that her vaginal delivery is safe and lscs should only be reserved for obstetric indications.I will alo make arrangements for her delivery to be at a centre equipped with the neonatalogy and neonate surgical services .This is because once delivery , the defect should be corrected within 24-48hours . I will also handle the bowels of the fetus with care upon delivery by wrapping them in sterile bag . The neonatalogy will be informed once patient is in labour . I will then also arrange for a joint consultation with the neonatalogy unit so that she can address any issues with the correction of the gastrochisis with relevant medical expertise. I will then provide her wriiten information regarding gastrochisis and also inform her that risk of recurrence is low in subsequent pregnancies.

  

Posted by gouthaman S.

 

Explain  about  the  condition  in  a sensitive  manner  with the  support  of  her  partner.Explain  about  the  nature  of  the  condition  `that  it  is  a  defect  in  the anterior  abdominal  wall  and  the  bowel loops  float  in  the  amniotic  cavity.The   prognosis  is  usually  good , more  than  90%  do  well  in  the absence  of  associated  structural  defects. Structural  defects  are  present  in  only  less  than 10%  of  the  casesThe  need  for  USG for  structural  defects  at  Fetal  medicine unit  is  explained to her..Karyotyping  is  usually  not  indicated  unless present  with  structural  defects.The  need  of  surgery  after  delivery  by  pediatric  surgeons  is  explained  to  her.The  increased  risk  of  IUGR,preterm delivery,bowel  compromise and  stiilbirth  are  told  to  her.The  need  for  increased  antepartum  surveillance  is  explained.Long  term  feeding  problems,bowel  complications   after  birth  are  told  to  her.She  is  reassured  that  most  of  the  problems  resolve  after  surgery.Her  attitude  regarding  pregnancy is  analysed.Options  of  continuation  of  pregnancy  and  termination  of  pregnancy  if  associated   structural  defects  are  discussed  with  her.She  is  counselled  that  recurrence  is  very  low  in  the  presence  of  isolated  defect.Information  leaflets  are  provided and  further  appointment  is  given.Contact  of  support  groups BEEP  is  provided  to  her

If  she  wishes  to  continue  pregnancy  arrangements  are  made  for  joint  counselling  with  multidisciplinary  team  including  pediatric surgeons,neonatologists.Serial  growth  scans  are  done  due  to  increased  risk  of  IUGR.Plan  of  care  regarding  antepartum care,mode  of  delivery ,place  of  delivery  are  discussed  with  her, her  partner  and  documented.Aim  for  vaginal  delivery.Ceserean section  is  done  for  obstetric  reasons.Due  to  risk  of  stillbirth  induction  of  labour  is  planned  at  37-38  weeks.Delivery  is  planned  at  tertiary  centre.Availability  of  pediatric  surgeons,neonatologists  are  ensured  prior  to  induction.. They  are  informed  in  the  event  of  labour and  during  induction.Continuous  electronic  fetal  monitoring  is  done  in  labour  due  to  risk  of  still birth.Appropriate  support  is  given  to  her  in  labour.After  delivery  the  abdominal  contents  are  wrapped  in  sterile  bags  to  prevent  contamination  and  infection.Due  to  absence  of  covering  membranes  early  surgery  is  required  than  for  exomphalos.Primary  closure  or  staged  procedure  is  done  depending  on  the  defect.Contact  of  support  groups like  BEEP is  provided to  her.

 

Posted by Christa R.

The first part of the counselling process would involve identifying a suitable environment to impart the news: private room, relative/partner present if possible, specialist midwife, interpreter if necessary. 

I would explain the nature of the condition, which is a defect in the baby's abdominal wall, to one side (usually the right side) of the umbilicus where abdominal contents (free floating loops of bowel) protrude and float within the baby's amniotic sac.  The defect occurs in ~1:3000 pregnancies.  It generally has a good prognosis, with >80% survival and is amenable to surgical correction when the baby is born.  It is occasionally ( max 10% of time) associated with other structural anomalies and therefore we would assess for any additional anomalies if not yet already performed.   Obviously the overall prognosis would depend on whether other anomalies are present.  Sometimes there is associated bowel atresia, which does carry a less favourable prognosis. There is a tendancy for babies with gastroschisis to be small (~30% <10th centile) and therefore serial growth scans at 28, 32 & 36 wks would be performed. This would also assess liquior volume which may be increased and  the bowel appearance There is also an increased risk of IUFD near term and therefore umbilical artery dopplers (+/- MCA dopplers) would be considered

The pregnancy would be managed in conjunction with  a fetal medicine team (Tertiary centre if not the 'home' hospital).  

The aim would be for IOL and vaginal delivery at 37-38 weeks (unless other indications for C/S) in a tertiary centre with the neonatal team on standby. There would be continous electronic fetal monitoring during labour and any decision for operative vaginal delivery would be the same as for usual obstetric indications. At delivery, the baby would be taken to NICU.  There would be gentle handling of the bowel which would be placed into a sterile plastic bag with saline.  Surgery would be arranged very soon after the birth to minimise any complications of exposed bowel.

ans Posted by Yingjian C.

During counselling, a sensitive approach is needed. I will explain the findings to patient: herniation of bowel contents thru abdominal wall of fetus. I will explain there is usually low risk of associated chromosomal or structural abnormalities of the fetus. I will explain there is a risk of bowel injury and the baby will need surgery after delivery. I will explain that the cause is not inherited- low risk of recurrence in next pregnancy. I will explain the prognosis of this condition is good after surgery. I will explore patient’s wishes to continue with pregnancy or to terminate, I will provide written information on the condition, support groups and counselling. I will provide patient with opportunity to discuss with neonatologist and paediatric surgeons. I will provide information and counselling if patient wants to terminate the pregnancy: will likely be medical termination needing feticide as she is already 20weeks gestation.

On management, I will take further history. I will ask on her obstetric history: number of children, any previous fetal anomalies, any previous gestational diabetes, mode of delivery, birthweight and apgar scores. I will ask on history of miscarriages or intrauterine deaths. For current pregnancy, I will ask if it is spontaneously conceived or artificial reproductive techniques required. I will ask if she is taking any folate this pregnancy. I will ask regarding down’s syndrome screening test this pregnancy, results of previous scans. I will ask on family history of down’s syndrome, other fetal abnormalities, diabetes mellitus. On examination, I will check on her blood pressure, body mass index. I will palpate uterine size if it is appropriate for dates.

 I will review her scans to check if there were any additional structural abnormalities or soft markers for aneuploidy or repeat a more detailed fetal anomaly scan if not done so. If not done before, I will offer her screening for down’s syndrome which will be a quadruple test at 20 weeks: this test has 70% detection rate and 5% false positive rate. If other structural abnormalities or soft markers are seen on the scan, I will offer her karyotyping which will be amniocentesis at 20 weeks gestation: there is 0.5-1% risk of miscarriage. I will screen her for oral glucose tolerance test is she has previous gestational diabetes, family history of diabetes, BMI>30 or previous macromic baby>4kg.  I will monitor the fetus with 3 weekly growth scans including AFI and umbilical artery dopplers.

A multidisciplinary approach is needed throughout management with neonatologists and paediatric surgeons. I will arrange appointments for patient to meet them. In her third trimester ,I will discuss with patient regarding delivery care plan. A normal vaginal delivery is not contraindicated: caesarean section only for other obstetric indications. An elective delivery is recommended at term after 39weeks so that planning can be coordinated for baby’s care by paediatric surgical team/neonatologists at time of delivery. The patient can have elective induction of labor or elective caesarean section if she declines vaginal delivery or other obstetric indications. The patient has to be delivered in consultant led maternity unit with neonatal resuscitation facilities.  If for normal vaginal delivery, the patient can have epidural if she requests. She will have intravenous access and group and save taken. Her venous thromboembolism risk has to be assessed antenatally, intrapartum and postpartum. Continuous external fetal monitoring during labor is needed. The neonatologist will have to standby delivery, NICU has to be informed close to time of delivery. Patient’s wishes have to be respected. Her pregnancy care plan must be clearly documented. 

 

 

Posted by FAUZIA  T.

I will explain the diagnosis to the woman in a sensitive manner, if possible her partner should be there. I will tell her that it is the defect of the abdominal wall from where the loops of the small intestine comes out.We need to do another detailed ultrasound to see if there are other structural anomalies. Usually, it is an isolated defect . It is not associated with chromosomal anomalies so karyotyping is not required. The woman should be referred to a tertiary centre.  Multidisciplinary team should be involved which includes consultant gynaecologist, paediatric surgeon, neonatologists. If isolated defect, the prognosis is usually good. The woman's wishes should be respected. If she wants to continue her pregnancy then the woman should have regular growth scans as the fetus is at risk of  premature labour, IUGR and stillbirth.Vaginal delivery is planned and CS is usually done for obstetric indications.Induction is planned at 37 weeks and in a place where neonatal facilities available.Continuous electronic fetal monitoring should be done.The loops of the intestine should be covered in a saline sterile bag.Surgery should be done immediately after delivery.The recurrence risk of this condition is very less.

Contact details of the support groups should be given.All the details of the care plan should be documented clearly.

Answer Essay Of Congenital anomaly Posted by Boody  H.

 

 

Counselling should be in a sympathetic manner ,in presence of her partner.

Counselling should be in liaison with tertiary fetal medicine unit.

She should be informed about the condition , that it is a defect in the anterior abdominal wall .

It is not related to the fetal umbilicus. It may contain an organ as a loop of small intestine.

She should be informed that is not associated with chromosomal abnormalities.  It is associated with increased maternal serum alfa-fetoptotein . She should be informed about the better prognosis than the omphaloceole .She should be informed that its recurrence is very low .  She should be informed that it is associated with fetal growth restriction , prematurity and the possibility of intrauterine fetal death . So, serial growth scan should be considered.

Information leaflet should be given to the woman .Her wishes should be respected regarding continuation of pregnancy or not.

Serial growth scan is recommended for fetal  growth restriction.Serial ultrasound also done for the liquor volume and  any abnormalties .

A meeting with neonatologist and pediatric surgeon should be arranged with the woman and her partner for the plan of postnatal management of the neonate.

Intramuscular    Betametazone should be given to the woman at 32-34 weeks for the possibility of the preterm delivery.

Delivery should be conducted at a unit , where pediatric surgery is available .

SCBU must be aware of the delivery in advance. Neonatologist should attend the delivery.

The aim of vaginal delivery , except if there is an obstetric indication of caesarean section or  the liver is extracorporeal.  

Posted by Lola B.

I will counsel the patient with sensitivity, knowing that this may cause distress to her. I will explain to her the nature of the abnormality, that there is a paraumbilical defect causing the bowels to herniate through. Assure her that she did not do anything wrong to cause this. 

She will need a detailed fetal anomaly scan, including a cardiac scan, to look for any other anomalies. If this is an isolated anomaly, then the chance of there being a chromosomal anomaly is very small and karyotype is not needed. Prognosis is usually good. Exact prognosis depends on what organs and viscera are involved. Prognosis is worse if liver is herniated. Antenatal problems include IUGR and sudden fetal intrauterine demise. Postnatally, the neonate may face feeding problems and growth probmels and may need parenteral feeding. The neonate will need an operation postnatally. There will be a chance to meet with the paediatric surgical team. 

I will counsel the patient on the risk of recurrence. IF there is no chromosomal abnormality, the risk of recurrence is very low. I will refer her to relevant councelling and support groups, and provide her with written information. A follow up visit will be scheduled.

 

Antenatally, she will be managed in a tertiary fetal medicine centre, under consultant led care. There has to be multidisciplinary management -- including the lead obstetrician, the midwife, the anaesthetist, neonatologist, paediatric surgeon and counsellor. The paitnet will be given a chance to meet and discuss postntal treatment with the paediatric surgical team. There will be reguar fetal growth scans, to monitor the fetal growth, amniotic fluid index and umbilical artery doppler flow. The aim is for expectant management and planned vaginal delivery at 37 weeks. Caesarean section is only for obstetric indications.

 

Delivery is planned in a tertiary centre with facilities for neonatal resuscitation and ICU care. Delivery has to be planned at 37 weeks at daylight hours, when anaesthetic, and paediatric support is fully available. The consultant obstetrician, paediatrician, midwife and anaesthetist should be informed once the paitnet is admitted in labour. The paediatrician has to be on standby at delivery. The herniated bowels are wrapped in warm sterile moist towels upon delivery.

 

 

Gastroschisis Posted by ALi S.
I will explain the diagnosis in a sensitive manner that Gastroschisis is congenital defect in fetal anterior abdominal wall . The defect leads to protrusion of fetal organs in particularly small bowels to free float in amniotic cavity . The condition is rarely associated with chromosomal abnormality<1%, so karyotyping is not recommended. Prognosis is usually good with survival rate 9:10 . After explaining the diagnosis ,the patient will be refereed to fetal centre for MDT discussion, the team involve paediatric surgeon, neonatologist , obstetrician. Antenatal risks mainly IUGR so serial USS for growth will be arranged. Information leaflet and support group like GEEPS will be provided. IOL will be offered at 38-39 weeks to avoid rare cases of IUFD. Delivery at tertiary fetal centre On admission paediatric surgeon and neonatalogist , paediatric anesthesist will be informed. Continuous monitoring during labour and CS will only be offered for obstetric indication.At delivery baby will be covered in plastic bag to avoid loss of fluid from the exposed bowels as well as to minimise risk of infection . Primary surgery is to repair the defect which carries the best prognosis. Baby will be kept in NICU post surgery and there is no contraindications for breast feeding. Post natal support and follow up with neonatal team to screen for the rare possibility of bowel atresia. Parents will be reassured before discharge about rare possibility of recurrence .
gastroschisis Posted by shraddha G.

 

The couple should be counselled in a sensitive manner with a notion that revealing the findings of anomaly scan could be a psychological trauma. Respect the privacy of couple as they may not want to reveal it to other family members. Ensure  private room availability for counselling.  Explain them that gastroschisis is an incidental finding and it cannot be screened with double or triple marker.  It is incidentally diagnosed with antenatal sonography or raised maternal serum AFP. Explain them sensitively as they must be annoyed that despite of all screening test , why such a major defect was left undiagnosed. Consultation should be done with multidisciplinary team involving consultant obstetrician, neonatologist, radiologist and consultant of neonatal surgical unit, preferably specialized in gastro-intestinal surgeries.

Explain the diagnosis made on anomaly scan in a simple language that gastroschisis is a type of hernia in which full thickness anterior abdominal wall fusion defect is present, usually on right paramedian side and intestine loops lie exposed in the amniotic fluid of baby. Usually it is a 2-5 cm defect. Explain that gastroschisis has no genetic association and familial occurrence is exceptionally rare. Reassure them that associated anomalies are uncommon with gastroschisis and if present would have been diagnosed on antenatal sonography. So, amniocentesis and karyotyping  is not recommended. Neonatal surgeon should explain the prognosis and outcome of the condition and explain that it has mortality rate of 17% approximately. Explain the couple that this condition has good prognosis and it is a correctable defect .Explain them that this condition is often associated with polyhydramnios, foetal growth restriction so serial growth scans are required at 28, 32 and 36 weeks. Foetal abdominal circumference is regarded as a standard reference for estimation of foetal weight , which is difficult to assess in this condition and  obstetric management is thus challenging. Explain them that this condition requires close antenatal follow-up, so as for inadvertent complications like foetal bowel obstruction, strangulation, delivery can be expedited. Delivery should be planned in a consultant-led unit, preferably at a tertiary centre. If delivery is planned at a peripheral centre, there should be easy access to neonatal surgical unit. Induction of labour is offered at 38 weeks of gestational age and caesarean section is indicated only for obstetric indications. Continuous electronic foetal monitoring is indicated during vaginal delivery.  Foetal outcome is quite not different with vaginal delivery or caesarean section. Post-natally baby should be immediately shifted to NICU and gentle handling of bowel should be done,put it in sterile plastic bag of normal saline. Surgery is performed on the same day of birth to avoid infection.  Bowel contrast studies and plain radiographs are required  to exclude other bowel complications.

my answer to essay 371 Posted by shazard S.

 

Regarding counseling recognize the potential for maternal anxiety and utilize a sensitive approach. Explain the ultrasound findings. Explain that gastroschisis refers to a para-umbilical defect in the anterior abdominal wall resulting in free floating bowel in the amniotic cavity. Re-assure that there is a high probability of long term survival and good outcome (>80%). Explain that there may be coexisting anomalies. Offer a detailed anomaly scan and cardiac ultrasound. Advise that gastroschisis is not associated with chromosomal abnormality when isolated. Advise that genetic screening is not necessary when gastroschisis is an isolated anomaly. Explain that if other anomalies detected genetic screening is advisable. Reassure her that recurrence of gastroschisis in subsequent pregnancies is rare. Explain that fetal effects include fetal growth restriction, polyhydramnios and preterm delivery. Explain the risk of late intra uterine fetal demise. Explain that neonatal effects include short bowel syndrome and feeding difficulty. Explain that corrective surgery is needed within 12hours of birth. Explain that this involves placing exposed bowel within the abdominal cavity and closure of the abdominal wall defect. Assess her views regarding termination of pregnancy (TOP) and respect her wishes. Arrange consults with a fetal medicine expert, paediatrician and paediatric surgeon. Offer written information and contacts for support groups. Regarding antenatal surveillance adopt a multi disciplinary team approach under a consultant lead obstetric unit. Manage with paediatricians, paediatric surgeons, fetal medicine expert and midwives. Offer increased frequency of follow up. Offer regular obstetric ultrasounds for fetal biometry and liquor volume to detect FGR and polyhydramnios. Offer a detailed fetal anmaly and cardiac scan to detect coexisting anomalies. Offer genetic testing if other anomalies exist. Document her bith plan by 36 weeks. Offer induction of labour at 37-38 weeks to avoid the risk of IUFD. Advise that vaginal delivery is appropriate and that caesarean section is indicated for obstetric reasons. Explain the benefits and risks of IOL. Timing of IOL should be in tandem with neonatal services. Regarding intrapartum care, ensure delivery in a consultant lead obstetric unit. The hospital must have facilities for advanced neonatal resuscitation and neonatal surgery. Ensure that paediatriians and surgeons attend delivery and that preparations are made for neonatal surgery. Ensure adequate analgesia and hydration. Employ continuous ctg monitoring. At delivery handle loops of bowel carefully and place loops within a sterile plastic bag. Ensure active management of third stage. Regarding post natal care advise  contraception and pre-conceptual counseling prior to subsequent pregnancies.  

gastroschisis Posted by lalitha N.

I would explain to her sensitively about the nature of the condition preferably with the support of her partner.Gastroschisis is a condition wherein there is a defect/hole in the anterior abdominal wall to one side of the umbilical cord, through which the intestines come out,develop outside the abdomen without a covering.Explain that there is no proven cause,no mode of prevention,association with smoking and recreational drugs,young maternal age suggested.she would be referred for a detailed second scan at a fetal medicine centre to exclude other structural abnormalities.In >90% of the cases no other anomalies present,good prognosis in such cases.Less than 1 in 10 can haveother problems like intestinal atresia.Karyotyping not necessary in the absence of other abnormalities since association with chromosomal problems rare.Increased chances of IUGR,preterm delivery,stillbirth ;hence need for more intensive monitoring explained.The baby needs immediate surgery after delivery,will be taken care of by neonatal team-paediatric surgeons,neonatologists-care for the baby after the surgery.the baby might have feeding difficulties in the initial 2-4 weeks after surgery,resolves later.Counselling sessions with paediatric surgeons can be arranged.Options of termination vs continuation of the pregnancy discussed;information leaflets,details of support groups-Antenatal results and choices,gastroschisis.co.uk,GEEPS given to her.She is told her decision would be respected and supported.

Once the decision to continue the pregnancy is made,she is offered regular follow up,serial scans to monitor growth,look for IUGR,bowel distension,hydramnios.Delivery is planned in a tertiary centre to ensure availability of specialists(paediatric surgeons) and NICU care. vaginal delivery is planned ;caesarean section only for obstetric indications.For purpose of availability of the neonatal team,and due to the increased risk of unexplained IUD,she may be offered induction of labour at 38 weeks.The neonatal team should be informed once she is induced,or comes in with labour or ruptured membranes or when CS is planned.In labour,there should be given continuous support,continuous electronic fetal monitoring due to high risk of fetal distress /demise. immediately after delivery,the bowel loops are wrapped in a sterile plastic bag to prevent infection.Surgery is planned the same day-primary closure/staged depending on the size of the defect and associated intestinal atresia.