Shirodkar operation and outcome
Volume 163 Number 3
et al! cites fetal survival rates after Shirodkar cerclage of75% to 85%. In our series 58 of the 66 treated pregnancies (88%) were carried for at least 37 weeks, with 61 surviving infants for an uncorrected perinatal survival rate of 92%. This is the largest published series of patients treated for incompetent cervix with the Shirodkar operation by a single surgeon. It demonstrates that the operation is effective when used for patients with documented cervical incompetence. There was no morbidity from the procedure, and removal of the Mersilene band as soon as labor began permitted vaginal birth without significantly increased risk to the mother or infant. The Shirodkar operation should be part of resident training and should have a prominent place in the treatment of incompetent cervix. Perhaps a prospective randomized
trial that compares the Shirodkar and McDonald procedures should be undertaken to determine the relative merits of these techniques. We thank Dennis S. Chi and Sara Truesdell for their assistance in preparation of the manuscript. REFERENCES 1. Lash AF, Lash SR. Habitual abortion: the incompetent internal os of the cervix. AM J OBSTET GYNECOL 1950;59:6876. 2. Shirodkar VN. A new method of operative treatment for habitual abortions in the second trimester of pregnancy. Antiseptic 1955;52:299-300. 3. McDonald IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Emp 1957;64:346-50. 4. Golan A, Barnan R, Wexler S, Langer R, Bukovsky I, David MP. Incompetence of the uterine cervix. Obstet Gynecol Surv 1989;44:96-107.
The effect of mode of delivery on the perinatal outcome in fetuses with abdominal wall defects Michael Moretti, MD, Aldo Khoury, MD, Jaime Rodriquez, MD, Thorn Lobe, MD, David Shaver, MD, and Baba Sibai, MD Memphis, Tennessee A descriptive study of 125 infants with abdominal wall defects was undertaken to determine the effect of mode of delivery on outcome. Fifty-six infants had gastroschisis and 69 had omphalocele. Overall, there were no differences between the omphalocele and the gastroschisis groups in either cesarean section rate (22% vs 26%) or prematurity rate (26% vs 30%). However, the omphalocele group had a significantly higher infant death rate (22% vs 7%, P < 0.001), a significantly higher incidence of associated major congenital anomalies (29% vs 5%, P < 0.001), and a higher inCidence of long-term infant morbidity (14.5% vs 8.9%). Within either group there was no significant difference between vaginal and cesarean delivery regarding either infant mortality, acute or long-term infant outcome, or frequency of associated major anomalies. We conclude that vaginal delivery of infants with abdominal wall defects does not adversely affect infant outcome. (AMJ OSSTETGvNECOL 1990;163:833-8.)
Key words: Congenital abdominal wall defects, vaginal delivery, outcome
The incidence of omphalocele is approximately one in 5,800 to one in 5,130 live births, while that of gastroschisis is about one in 10,000 to one in 15,000 live births.' Omphalocele represents the persistence of the body stalk in an area normally occupied by the differFrom the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Tennessee, Memphis. Presented at the Tenth Annual Meeting of the Society of Perinatal Obstetricians, Houston, Texas, January 23-27, 1990. Reprint requests: Michael Moretti MD, Crump Women's Hospital, Room E100, 853 Jefferson Ave., Memphis TN 38163. 616122583
entiated abdominal wall. A membranous sac usually covers the herniated viscera. Omphalocele is associated with major chromosomal abnormalities. This is reported to be as high as 40% of patients where amniocentesis is performed. In addition, there is an increased incidence of other major structural abnormalities (45%) Gastroschisis involves a defect in the abdominal wall usually to the right of the umbilicus. It has been suggested that this results from abnormal involution ofthe right umbilical vein that leads to a paraumbilical defect through which small bowel prolapses at approximately 37 days of embryonic life. In gastroschisis, viscera float
833
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uncovered in the amniotic fluid and lie exposed at birth. The incidence of major chromosomal abnormalities or other structural anomalies is low in this group of fetuses «5%). Prematurity and low birth weight have been reported to be more common than in omphalocele. 2.' There has been an increase in the survival of infants with these defects over the past 10 years. Mortality is related to a number of factors: gestational age at the time of delivery, the condition of the infant before operation, the presence of other anomalies, the size of the lesion, and the type of repair.' Now, with the widespread use of obstetric ultrasonography, congenital defects of this sort are being detected in utero with increasing frequency.6 Since prenatal diagnosis offers the ability to alter the obstetric management, it is important to focus attention on other perinatal factors that may influence neonatal and long-term outcome. Debate has arisen as to the appropriate mode of delivery. Early case reports advocated the use of cesarean section to avoid fetal injury.7-9 Lenke et al. 10 recommended the use of cesarean section in fetuses with gastroschisis while Nakayama et al. 11 and Kirk and Wah' reported that vaginal delivery did not appear to adversely affect fetal outcome for these fetus. In addition, Carpenter et al. 12 reported that vaginal delivery is not contraindicated for the fetus with ventral wall defects. The purpose of this report is to review our experience of 125 cases of anterior abdominal wall defects and to determine the effect of mode of delivery on neonatal survival and long-term outcome. Material and methods
The study group consisted of infants with om ph alocele or gastroschisis who were referred to the neonatal surgical team at the University of Tennessee, Memphis, between August 1978 and July 1989. Data were collected by chart review performed by the authors. The source of the data included office records of the pediatric surgical team, inpatient and outpatient records of the hospital of origin, records from the neonatal intensive care unit, and, when applicable, autopsy reports. Details of long-term follow-up were obtained from the pediatric clinic that the patients attended and by direct contact with the parents of the infants. Records were reviewed for birth weight, gestational age, mode of delivery, presence of other major anomalies, size of the defect, and presence of extracorporeal organs, as well as the presence of other neonatal complications. Special attention was given to the ascertainment of trauma to the extracorporeal organs at delivery and, in the case of omphalocele, rupture of the sac. In those cases of omphalocele with a ruptured sac records were carefully reviewed to determine those that appeared to occur at delivery. This was determined principally by observations of the bowel serosa and the pres-
September 1990 Am J Obstet Gynecol
ence of thickened matted bowel. It was thought that those infants who had these associated bowel findings most likely sustained rupture of the omphalocele sac before delivery. The changes in the bowel serosa were attributed to exposure of the bowel to the alkaline amniotic fluid, similar to that of gastroschisis. Gestational age at birth was estimated from the mother's last menstrual period and confirmed where possible by a dating ultrasonogram and Dubowitz examination. Definition of the extent of the ventral wall defect and evidence of any trauma were based on records of the examination by the pediatric surgical team on admission to their unit. The criteria defined by the pediatric surgical team for the diagnosis of omphalocele included those patients with a midline abdominal wall defect with a covering membrane or a remnant of the membrane. Additional criteria included the presence of a dilated umbilical ring containing umbilical vessels passing through the membranous sac without an intervening bridge. The criteria for the diagnosis of gastroschisis were a paraumbilical full-thickness defect of the abdominal wall and a normal umbilical cord insertion independent of the defect with a skin bridge between the ventral defect and the umbilical ring. The analysis was focused on perinatal outcome, longterm outcome, incidence of surgical complications, and cause of death. The infants were divided into four groups according to mode of delivery for analysis: gastroschisis vaginal group versus gastroschisis cesarean section group and omphalocele vaginal group versus omphalocele cesarean section group. Analysis of data was performed with X2 or Fisher's exact test when appropriate and by Student's t test. A p value of
Volume 163 Number 3
et al! cites fetal survival rates after Shirodkar cerclage of75% to 85%. In our series 58 of the 66 treated pregnancies (88%) were carried for at least 37 weeks, with 61 surviving infants for an uncorrected perinatal survival rate of 92%. This is the largest published series of patients treated for incompetent cervix with the Shirodkar operation by a single surgeon. It demonstrates that the operation is effective when used for patients with documented cervical incompetence. There was no morbidity from the procedure, and removal of the Mersilene band as soon as labor began permitted vaginal birth without significantly increased risk to the mother or infant. The Shirodkar operation should be part of resident training and should have a prominent place in the treatment of incompetent cervix. Perhaps a prospective randomized
trial that compares the Shirodkar and McDonald procedures should be undertaken to determine the relative merits of these techniques. We thank Dennis S. Chi and Sara Truesdell for their assistance in preparation of the manuscript. REFERENCES 1. Lash AF, Lash SR. Habitual abortion: the incompetent internal os of the cervix. AM J OBSTET GYNECOL 1950;59:6876. 2. Shirodkar VN. A new method of operative treatment for habitual abortions in the second trimester of pregnancy. Antiseptic 1955;52:299-300. 3. McDonald IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Emp 1957;64:346-50. 4. Golan A, Barnan R, Wexler S, Langer R, Bukovsky I, David MP. Incompetence of the uterine cervix. Obstet Gynecol Surv 1989;44:96-107.
The effect of mode of delivery on the perinatal outcome in fetuses with abdominal wall defects Michael Moretti, MD, Aldo Khoury, MD, Jaime Rodriquez, MD, Thorn Lobe, MD, David Shaver, MD, and Baba Sibai, MD Memphis, Tennessee A descriptive study of 125 infants with abdominal wall defects was undertaken to determine the effect of mode of delivery on outcome. Fifty-six infants had gastroschisis and 69 had omphalocele. Overall, there were no differences between the omphalocele and the gastroschisis groups in either cesarean section rate (22% vs 26%) or prematurity rate (26% vs 30%). However, the omphalocele group had a significantly higher infant death rate (22% vs 7%, P < 0.001), a significantly higher incidence of associated major congenital anomalies (29% vs 5%, P < 0.001), and a higher inCidence of long-term infant morbidity (14.5% vs 8.9%). Within either group there was no significant difference between vaginal and cesarean delivery regarding either infant mortality, acute or long-term infant outcome, or frequency of associated major anomalies. We conclude that vaginal delivery of infants with abdominal wall defects does not adversely affect infant outcome. (AMJ OSSTETGvNECOL 1990;163:833-8.)
Key words: Congenital abdominal wall defects, vaginal delivery, outcome
The incidence of omphalocele is approximately one in 5,800 to one in 5,130 live births, while that of gastroschisis is about one in 10,000 to one in 15,000 live births.' Omphalocele represents the persistence of the body stalk in an area normally occupied by the differFrom the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Tennessee, Memphis. Presented at the Tenth Annual Meeting of the Society of Perinatal Obstetricians, Houston, Texas, January 23-27, 1990. Reprint requests: Michael Moretti MD, Crump Women's Hospital, Room E100, 853 Jefferson Ave., Memphis TN 38163. 616122583
entiated abdominal wall. A membranous sac usually covers the herniated viscera. Omphalocele is associated with major chromosomal abnormalities. This is reported to be as high as 40% of patients where amniocentesis is performed. In addition, there is an increased incidence of other major structural abnormalities (45%) Gastroschisis involves a defect in the abdominal wall usually to the right of the umbilicus. It has been suggested that this results from abnormal involution ofthe right umbilical vein that leads to a paraumbilical defect through which small bowel prolapses at approximately 37 days of embryonic life. In gastroschisis, viscera float
833
834
Moretti et al.
uncovered in the amniotic fluid and lie exposed at birth. The incidence of major chromosomal abnormalities or other structural anomalies is low in this group of fetuses «5%). Prematurity and low birth weight have been reported to be more common than in omphalocele. 2.' There has been an increase in the survival of infants with these defects over the past 10 years. Mortality is related to a number of factors: gestational age at the time of delivery, the condition of the infant before operation, the presence of other anomalies, the size of the lesion, and the type of repair.' Now, with the widespread use of obstetric ultrasonography, congenital defects of this sort are being detected in utero with increasing frequency.6 Since prenatal diagnosis offers the ability to alter the obstetric management, it is important to focus attention on other perinatal factors that may influence neonatal and long-term outcome. Debate has arisen as to the appropriate mode of delivery. Early case reports advocated the use of cesarean section to avoid fetal injury.7-9 Lenke et al. 10 recommended the use of cesarean section in fetuses with gastroschisis while Nakayama et al. 11 and Kirk and Wah' reported that vaginal delivery did not appear to adversely affect fetal outcome for these fetus. In addition, Carpenter et al. 12 reported that vaginal delivery is not contraindicated for the fetus with ventral wall defects. The purpose of this report is to review our experience of 125 cases of anterior abdominal wall defects and to determine the effect of mode of delivery on neonatal survival and long-term outcome. Material and methods
The study group consisted of infants with om ph alocele or gastroschisis who were referred to the neonatal surgical team at the University of Tennessee, Memphis, between August 1978 and July 1989. Data were collected by chart review performed by the authors. The source of the data included office records of the pediatric surgical team, inpatient and outpatient records of the hospital of origin, records from the neonatal intensive care unit, and, when applicable, autopsy reports. Details of long-term follow-up were obtained from the pediatric clinic that the patients attended and by direct contact with the parents of the infants. Records were reviewed for birth weight, gestational age, mode of delivery, presence of other major anomalies, size of the defect, and presence of extracorporeal organs, as well as the presence of other neonatal complications. Special attention was given to the ascertainment of trauma to the extracorporeal organs at delivery and, in the case of omphalocele, rupture of the sac. In those cases of omphalocele with a ruptured sac records were carefully reviewed to determine those that appeared to occur at delivery. This was determined principally by observations of the bowel serosa and the pres-
September 1990 Am J Obstet Gynecol
ence of thickened matted bowel. It was thought that those infants who had these associated bowel findings most likely sustained rupture of the omphalocele sac before delivery. The changes in the bowel serosa were attributed to exposure of the bowel to the alkaline amniotic fluid, similar to that of gastroschisis. Gestational age at birth was estimated from the mother's last menstrual period and confirmed where possible by a dating ultrasonogram and Dubowitz examination. Definition of the extent of the ventral wall defect and evidence of any trauma were based on records of the examination by the pediatric surgical team on admission to their unit. The criteria defined by the pediatric surgical team for the diagnosis of omphalocele included those patients with a midline abdominal wall defect with a covering membrane or a remnant of the membrane. Additional criteria included the presence of a dilated umbilical ring containing umbilical vessels passing through the membranous sac without an intervening bridge. The criteria for the diagnosis of gastroschisis were a paraumbilical full-thickness defect of the abdominal wall and a normal umbilical cord insertion independent of the defect with a skin bridge between the ventral defect and the umbilical ring. The analysis was focused on perinatal outcome, longterm outcome, incidence of surgical complications, and cause of death. The infants were divided into four groups according to mode of delivery for analysis: gastroschisis vaginal group versus gastroschisis cesarean section group and omphalocele vaginal group versus omphalocele cesarean section group. Analysis of data was performed with X2 or Fisher's exact test when appropriate and by Student's t test. A p value of
