O&G Forum

OBSTETRICS & GYNAECOLOGY FORUM 2022 | ISSUE 3 | 15 With regards to omphalocoele, liver herniation is thought to be a significant predictor of adverse outcome. 4 Almost 60% of foetuses in the omphalocoele subset were classified as major omphalocoeles in this study. There was a statistically significant difference in having surgery between a minor and major omphalocoele, with those with minor omphalocoele being more likely to have surgery than those with major omphalocoele. Of these neonates with giant omphalocoele, 35.7% demised but this was not shown to be statistically significant compared to those infants with omphalocoele who demised without liver herniation. According to Cohen-Overbeek et al, the survival rate of isolated omphalocoele is as high as 96%. 12 It was determined that the survival rate of isolated omphalocoele in this study was 87% (13/15). In the literature, few studies have looked at the association between polyhydramnios and omphalocoele. A study by Ozawa et al found associated anomalies in all patients where polyhydramnios was detected on ultrasound. 13 In this study, twenty eight percent (28%) of all omphalocoele cases were found to be complicated by polyhydramnios with just over half of these cases having an associated anomaly and subsequent mortality. According to the literature, with regards to gastroschisis, bowel dilatation has been the most widely reviewed prenatal parameter for correlation with postnatal morbidity. 8,9 More recently intra-abdominal bowel dilatation has been linked to complex gastroschisis which increases the risk of a poor outcome. 8 Dilated bowel (intra and extra abdominal) was evident on prenatal ultrasound in 50% (17/34) of the foetuses and measurements ranged from 10.9mm to 35mm. One case displayed both intra and extra bowel dilatation. Just 2 babies with bowel dilatation demised, one with extra-abdominal dilatation of 20mm and the other with intra-abdominal bowel dilatation of 16mm. Badillo et al suggest that bowel dilation is not predictive of bowel atresia, in part because bowel dilation is a common finding in foetuses with gastroschisis and this study supports that finding. 9 Japaraj et al found polyhydramnios to be associated with severe bowel complications. 14 Pertaining to this study there were 6/34 (17.6%) cases of polyhydramnios on ultrasound and bowel complications were not encountered, nor were there any effects on outcomes at birth. Few studies have evaluated gastric dilatation as a marker for complex gastroschisis. 8 There may possibly be an association between gastric dilatation and death as 2 out of the 4 cases with this finding demised. Herniation of liver and stomach is known to be rare in gastroschisis. 6,8 This finding was observed in 3 foetuses of the gastroschisis subset but did not affect mortality. There was only one case noted to have thickened bowel of 4.5mm but a good outcome prevailed. Newer studies pertaining to abdominal wall defects do not show any significant difference between caesarean section and vaginal delivery in terms of neonatal mortality and morbidity. 15 In this study it is evident that abdominal delivery is the preferred mode (90%). There is no institutional policy at IALCH mandating delivery via Caesarean section for an AAWD, however, an elective delivery does allow for better co- ordination between timing of delivery and postnatal care by the neonatal intensivists and paediatric surgeons. Of the 10% (6/59) that delivered vaginally, 2 babies demised from sepsis. In none of the cases was labour induced. Fifty two percent (52%) of the omphalocoele neonates were managed without surgical intervention. Half of these were poor surgery candidates and the other half were managed conservatively (with flamazine and jelonet dressings), with the defect either being too small or too large in size. Specific non-operative techniques are generally employed for giant omphalocoeles which involves the use of dressings over the defect, which epithelialises over time, leaving a ventral hernia that can be corrected later in life. 2, 16 The time to full oral feeds gives an indication of the condition of the bowel as well as the neonate as a whole. 17 Patients with gastroschisis, compared to omphalocoele, require longer periods of parenteral nutrition and have longer hospital stay. 8,9,18 Mortality rates are known to be high in babies diagnosed with omphalocoele because of the risk of chromosomal abnormalities as well as other associated structural abnormalities. 1,19,20 Neonatal mortality rates with gastroschisis can be as high as 5-10%. 12 This study revealed a higher mortality rate of 32% in the omphalocoele group compared to 15% in the gastroschisis group with the most common cause of death in both groups being sepsis. On the other hand, an African study conducted in 2011 encountered higher mortality rates in gastroschisis compared to omphalocoele. 21 Sekabira et al in 2009 evaluated all neonates diagnosed with gastroschisis at IALCH over a 5 year period. This study showed a mortality rate of 43% with sepsis being the leading cause. 22 It appears there has been a significant reduction in deaths over the last 10 years in neonates with gastroschisis and this indicates vast improvements in postnatal care. Limitations Unfortunately majority of neonates born with gastroschisis and omphalocoele were delivered outside of the institution. Patients transferred to IALCH from peripheral sites were not in possession of their antenatal records hence review of these charts was not possible. Owing to the fact that ultrasound reports were not accessible in the majority of patients, the actual detection rate for AAWD could not be calculated. Those patients who suffered an intrauterine death and those that opted for TOP were excluded from this study but in actual fact this could have shed light on specific severe gastrointestinal abnormalities that warranted a TOP or resulted in an IUD. Some of the neonates were transferred out of the NICU intubated, thus their survival outside of IALCH is unknown. Long term outcomes of the surviving neonates were not evaluated. In addition, the small sample size limited our ability to provide strong statistical links between ultrasound findings and outcomes but provides valuable information on the conditions in our setting in terms of care and future planning. Conclusion Since foetal anterior abdominal wall defects are correctable lesions, when not associated with multiple malformations or chromosomal abnormalities, the prenatal detection as well as appropriate management strategy constitutes an important priority. In the public sector paediatric surgeons are only available in tertiary institutes and delivery should be undertaken at these institutions so as to minimise bowel O&G Forum 2022; 32: 11-16 ORIGINAL RESEARCH