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Division of Neonatology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
Division of Neonatology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
The objective of this study was to review the medical literature that has reported the risk for intrauterine fetal death (IUFD) in pregnancies with gastroschisis.
Study Design
We systematically searched the literature to identify all published studies of IUFD and gastroschisis through June 2011 that were archived in MEDLINE, PubMed, or referenced in published manuscripts. The MESH terms gastroschisis or abdominal wall defect were used.
Results
Fifty-four articles were included in the metaanalysis. There were 3276 pregnancies in the study and a pooled prevalence of IUFD of 4.48 per 100. Those articles that included gestational age of IUFD had a pooled prevalence of IUFD of 1.28 per 100 births at ≥36 weeks' gestation. The prevalence did not appear to increase at >35 weeks' gestation.
Conclusion
The overall incidence of IUFD in gastroschisis is much lower than previously reported. The largest risk of IUFD occurs before routine and elective early delivery would be acceptable. Risk for IUFD should not be the primary indication for routine elective preterm delivery in pregnancies that are affected by gastroschisis.
However, there remain many questions about perinatal management and, in particular, about the optimal gestational age at delivery. Intrauterine fetal death (IUFD) is more common in pregnancies that are affected by congenital anomalies. Among all major congenital anomalies, 2% of pregnancies result in stillbirth,
Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats. Available at: http://www.cdc.gov/nchs/vitalstats.htm. Accessed Aug. 21, 2012.
This higher risk of stillbirth results in a higher frequency and level of antenatal monitoring and, in some cases, elective delivery at <39 weeks' gestation.
yet the average age of delivery is approximately 1 week earlier. This discrepancy leads to the conclusion that infants with gastroschisis deliver early either for fetal/maternal indications or electively.
Although some clinicians advocate for early delivery to improve postnatal clinical outcomes (such as earlier initiation of enteral feeds and shorter hospitalization time), the literature does not document a consistent benefit.
Is unexplained third trimester intrauterine death of fetuses with gastroschisis caused by umbilical cord compression due to acute extra-abdominal bowel dilatation?.
Studies that have documented high rates of IUFD are limited by small numbers, and many were conducted at a time when prenatal diagnosis of gastroschisis was uncommon. These studies found that most IUFDs occurred late in the third trimester. Obstetricians developed the practice of early elective delivery based on these studies. Additional studies that have suggested lower rates of IUFD are also limited by sample sizes and evaluations of single institutions or populations. Our own experience suggests a much lower rate of IUFD than 10-12%. The limitations of individual studies compromise ascertainment of the true incidence of IUFDs with gastroschisis.
We present a metaanalysis to generate a more accurate representation of the prevalence of IUFD among infants with prenatal diagnosis of gastroschisis. We hypothesize that the prevalence of IUFD is less than previously reported and that the risk of IUFD does not vary with gestational age.
Materials and Methods
We conducted a metaanalysis of the published, English-language literature that is related to gastroschisis.
Literature search
A systematic search was done independently by 2 of the authors (A.S., K.S.) who reviewed the literature to identify all published studies through June 2011 that were archived in MEDLINE and PubMed or were referenced in published articles. The MESH terms gastroschisis or abdominal wall defect were used. Abstracts were reviewed initially and excluded based on predetermined criteria that included non-English language, nonhuman subjects, or no relation to gastroschisis. The remaining articles were selected for full text review, which led to further exclusion of articles that did not report the number of IUFDs, case reports, studies with small sample sizes (n <10), and datasets that did not represent the total population (eg, case series of live births with gastroschisis or if the total number of pregnancies with gastroschisis was not disclosed). When there were multiple studies that used the same dataset, we included only 1 article and prioritized the article that reported the gestational age of IUFD. If both articles reported gestational age at IUFD, the article with the larger number of infants was included. The included articles were divided into those with a stated gestational age at IUFD and those without.
Data extraction
Data regarding all reported pregnancies, including termination of pregnancy, were extracted independently from all included studies by 2 authors (A.S., K.S.). Extracted data included gestational age at delivery, gestational age at IUFD, country of origin, year the study was published, presence of comorbidities in addition to gastroschisis, and obstetric delivery plan. IUFD was defined as an unplanned fetal death or stillbirth at any gestational age. The mean or median gestational age at delivery was extracted for each study. Early delivery plan was defined as systematic elective delivery at any predefined gestational age, compared with awaiting the onset of spontaneous labor or delivery because of maternal or fetal indications.
Quality assessment
A scoring system that was based on a previous metaanalysis was used to create a grading scale for the articles.
Studies were independently graded (A.S., K.S.) with the use of a standardized evaluation form that had been developed for the purpose of this metaanalysis. Each study was assigned a grade of 1-5 according to the quality of reporting of 5 factors. Variables were chosen to represent the factors that we believed to be essential for contributing valid data (population-based data, prospective data collection) or essential for understanding results (identified obstetric delivery plan, reported gestational age at birth, and reported gestational age at the time of IUFD). Differences between reviewers' grades were resolved by consensus among all 3 authors. The quality markers that were chosen for this study were identified before the start of data abstraction. The rate of IUFD was compared among studies on the basis of the assigned quality assessment scores.
Statistical analysis
The rate of IUFD was calculated for each study with the number of IUFDs reported in the numerator and the number of live births plus IUFDs in the denominator. Pregnancies that were terminated electively were not included in the numerator or denominator, because these pregnancies were considered not at risk for an IUFD. A random-effects model was used to aggregate individual effect sizes to create a pooled prevalence of IUFD. Random-effects models are based on the assumption that the studies that were selected for analysis are a sample of all potential studies by incorporating between-study variability in the overall pooled estimation.
Pooled prevalence estimates of IUFD with 95% confidence intervals were reported from these models with the use of the Der Simonian-Laird random-effects method.
All rates were calculated as deaths per 100 total births, with total births being the summation of live births and fetal deaths. Subgroup analyses were performed for the prevalence of IUFD with the following stratifications: gestational age, early delivery plan, study site (within US vs international), study grading, and years in which the study occurred.
Homogeneity across studies was tested with the I2 index, which provides a measure (or percentage) of the variation in prevalence attributable to between-study heterogeneity.
Post-hoc sensitivity analyses were conducted to investigate the potential sources of heterogeneity from specific studies that may have biased the analyses. Studies that potentially influenced heterogeneity were removed from analyses, and the results were compared with the original findings. A forest plot was created to illustrate the prevalence of each study, with 95% confidence intervals, that contributed to the analysis along with the pooled prevalence estimate. Finally, all studies that reported mean/median gestational ages of the live births of gastroschisis were divided into 3 time periods: before 1990, 1990-1999, and after 2000. The mean/median birth rates of gastroschisis were described for each time period to determine trends in timing of delivery.
Results
Study and patient characteristics
Our search produced 1123 results. Review of these abstracts resulted in 100 articles for further review (Figure 1). Six articles
One article was removed because it did not appear to study consecutive cases of pregnancies that were affected by gastroschisis and thus did not reflect the total population at risk,
and 3 additional articles were excluded for being case reports. We included 54 eligible studies in the final statistical analysis (Figure 2). Thirty-five studies reported information regarding gestational ages at the time of the IUFD and/or a mean or median gestational age at delivery. Nineteen articles included the total number of IUFDs but did not provide the gestational age of each IUFD.
Flow diagram shows the number of citations that were identified, the exclusions with indications, and the total articles for further analysis that are separated into those citations that included gestational age (GA) for intrauterine fetal death (IUFD) and those without.
South. Risk of IUFD in gastroschisis. Am J Obstet Gynecol 2013.
Final eligible studies included 3276 total pregnancies that were affected by gastroschisis (IUFD plus live births) and 177 IUFDs. Of the 54 studies that were included, 12 studies (22%) reported no IUFDs (Table 1). Sixteen studies (30%) reported a planned elective delivery before onset of labor. Seventeen studies (32%) took place in the United States. The median gestational age of 48 IUFDs for which information was available was 33 weeks (range, 18–41 weeks). For those studies that reported a mean or median gestational age, the average reported mean or median gestational age at delivery for included studies was 35.7 weeks (median, 36 weeks; range of medians, 34–37 weeks). Only 4 studies (7.4%) had a quality grade of 5 (the highest quality). Twenty-two studies (40.7%) had a grade of 4; 14 studies (25.9%) had a grade of 3; 11 studies (20.4%) had a grade of 2, and only 3 studies had the lowest grade of 1 (Table 2).
Table 1Characteristics of the studies that were included in the systematic review
Omphalocele and gastroschisis: prenatal diagnosis and peripartal management: a case analysis of the years 1989-1997 at the Department of Obstetrics and Gynecology, University of Homburg/Saar.
Sonographic assessment of the extra-abdominal fetal small bowel in gastroschisis: a retrospective longitudinal study in relation to prenatal complications.
Deliver at >29 wks' gestation and 3/4 criteria: (1) maximum bowel diameter >10 mm, (2) wall thickness >2 mm, (3) lack of peristalsis, (4) intestinal matting
Canadian Pediatric Surgical Network: a population-based pediatric surgery network and database for analyzing surgical birth defects: the first 100 cases of gastroschisis.
The pooled prevalence of IUFD for all studies was 4.48 per 100 gastroschisis pregnancies (live births + IUFD; 95% confidence interval [CI], 3.48–5.76). There was no significant difference in IUFD rate between centers with and without an early delivery plan in place (prevalence, 4.09; 95% CI, 2.39–6.91 vs 4.64; 95% CI, 3.47–6.17 per 100 births, respectively; P = .7). The mean gestational age at delivery for those studies that reported an early delivery plan was not different from those studies in which there was no delivery plan (prevalence, 35.5 ± 0.83 (SD) vs 35.8 ± 0.85; P = .22). There was also no difference in IUFD rate between studies conducted in the United States vs outside the United States (prevalence, 3.65; 95% CI, 2.26–5.84 vs 4.89; 95% CI, 3.63–6.56; P = .30). Twenty-two of the 54 publications (40.7%) reported on study populations or study sites within the United States while 3 were from Canada. Three studies were from Asia (2 Japan, 1 China), and 1 study was from South America (Brazil). The remaining studies were from the United Kingdom, Europe, or Australia. The 3 studies from Asia had relatively high rates of IUFD that ranged from 8.33–15.38 per 100 births. These studies also had study years beginning in the 1980s; therefore, rates may reflect the practices of that region and time. The prevalence of IUFD across the publication years was quite variable, with a range from 0 (2000 and 2004) to 13.8 per 100 births (2010). The highest rates occurred in 1986 (13.3 per 100 births), 1990 (13.4 per 100 births), and 2010. No significant trends were seen among other years (P = .8, with the use of a simple regression model).
Thirty-five articles described gestational age at the time of IUFD, which totaled 37% (n = 66) of all identified IUFDs. Fourteen of 66 IUFDs (21%) occurred at ≥36 weeks' gestation. Figure 3 shows the prevalence of IUFD at each gestational age and cumulative prevalence of IUFD across each gestational age. Nineteen percent of IUFDs occurred at ≤30 weeks' gestation. The pooled prevalence of IUFD that occurred at ≥36 weeks' gestation was 1.28 per 100 births (95% CI, 0.72–2.26). The weekly prevalence of IUFD did not appear to increase at >35 weeks' gestation. The difference between this graph of crude prevalence estimates and the pooled prevalence estimates for gestational age of ≥36 weeks is that the metaanalysis included all IUFDs that occurred at ≥36 weeks, although the graph only includes IUFDs up to 38 weeks' gestation. In addition, the metaanalysis weights the prevalence calculations based on sample size of the studies, which can also add to the differences in the 2 point estimates.
Figure 3Prevalence of intrauterine fetal death by gestational age
Cumulative and weekly prevalence of intrauterine fetal death per 100 pregnancies. Blue lines indicate weekly prevalence of intrauterine fetal death; red lines indicate cumulative prevalence of intrauterine fetal death.
South. Risk of IUFD in gastroschisis. Am J Obstet Gynecol 2013.
Thirty-seven studies reported a mean/median gestational age for live births. The proportion of deliveries that occurred at 37 weeks' gestation was no different between the 90s and 2000s (2 decades, 14% and 15.8%, respectively). The proportions that occurred at 36 weeks' gestation were 50% and 37%, respectively. The proportions that occurred at 35 weeks were 21.4% and 42%, respectively. This temporal pattern did not vary significantly when alternative grouping strategies were used.
Twenty-eight studies reported at least 1 termination of pregnancy. There was no difference in the prevalence of IUFD among studies that reported a termination of pregnancy and studies that had none or were not reported (P = .63). The pooled prevalence of IUFD among studies with elective termination was 4.21 (95% CI, 2.93–6.03), compared with 4.77 (95% CI, 3.32–6.81) among studies without a case of elective termination.
The 12 studies in which there were no reported fetal death included a total of 369 cases. These studies, which represent 11% of the total number of cases that were included in the metaanalysis, appeared to have a slightly lower gestational age at delivery (35.1 ± 0.99 weeks), compared with studies that reported at least 1 IUFD (35.9 ± 0.70 weeks; P = .01). We were unable to identify a pattern of differences in management or study methods between those studies with and those without reported IUFDs in terms of quality score, geographic location, or reporting of an obstetric delivery plan.
Sensitivity analysis
A pooled prevalence was calculated that included only those studies (n = 35) that reported a gestational age at the time of the IUFD. Among the 35 articles, there were 1483 infants (births + IUFDs) and 60 IUFDs. The pooled prevalence among these studies was 3.80 (95% CI, 2.68–5.35), which is consistent with findings of all included studies. When we restricted the analysis only to the 26 studies that had a quality grade of 4 or 5 (n = 1411 IUFD + live births), the pooled prevalence was 5.6 per 100 births (95% CI, 4.01–7.89). Among the 14 studies with lowest quality grades of 1 or 2, the pooled prevalence rate was 4.49 (95% CI, 2.81–7.08; Table 2). None of the 5 quality assessment variables were related independently to risk for IUFD.
Heterogeneity
We detected moderate heterogeneity across studies (I2 = 63%), which indicated moderate between-studies variability. This likely is due to differences in the definition of IUFD (gestational age cutoff for spontaneous abortion vs IUFD) and practice variability in the management of gastroschisis pregnancies. Because 12 studies reported no cases of IUFD, these 12 studies were not included in the initial assessment of heterogeneity (they provided no estimates of variances for prevalence rates). To estimate their contribution if they had reported IUFDs, we assumed 1 case occurred in each study and then recalculated the I2, which decreased slightly from 63% to 56%. We investigated each study's individual contribution to the heterogeneity by removing each study individually from the analysis and recalculating the pooled results, which included the assessment of the 12 studies that had the largest sample sizes (n > 100). Results indicated that the article by Calzolari et al
(prevalence, 14.6 per 100 births; 95% CI, 10.78–19.16) contributed the most to the I2 (pooled prevalence without the study of Calzolari et al, 4.47; 95% CI, 3.46–5.76; I2 = 55%]. Skarsgard et al
Canadian Pediatric Surgical Network: a population-based pediatric surgery network and database for analyzing surgical birth defects: the first 100 cases of gastroschisis.
also contributed significantly to the heterogeneity (prevalence, 0.94 per 100 births; 95% CI, 0.05–4.56; pooled prevalence without Skarsgard, 4.40; 95% CI, 3.40–5.67; I2 = 43%]. The removal of both of these studies decreased the I2 to 46%.
Comment
The optimal timing for delivery of infants with gastroschisis is unknown, because there are both risks and benefits associated with elective delivery before term. The possibility of fetal death is a major factor in the determination of appropriate obstetric management. The identification of an accurate risk profile for IUFD is essential for clinicians to assess risks and benefits appropriately and therefore develop an obstetrics management plan.
In the general population, late preterm delivery (34-36 weeks' gestation) is associated with increased morbidity and mortality rates. Among a cohort of infants without congenital anomalies, Young et al
showed decreasing mortality rates at 34, 35, and 36 weeks' gestation, compared with term infants (risk ratio, 10.5, 7.2, and 5.3, respectively). Neonatal intensive care unit admissions for respiratory issues were also more common among infants who were born late preterm.
Longer-term complications have also been described. Late preterm infants were found to have increased intensive care admissions because of respiratory syncytial virus, with increased length of hospitalization, compared with term infants.
Because of these apparent risks that are associated with early delivery, the March of Dimes is leading an effort to reset the obstetric paradigm by advocating a decrease in the number of normal pregnancies electively delivered at <39 weeks' gestation.
The published literature on long-term developmental outcomes that are associated with gastroschisis is sparse, which leaves us with little data regarding the effect of gestational age on these outcomes. Although children with gastroschisis have been reported to have both normal
studies have been limited by small sample sizes, noncontemporary cohorts, and a lack of formal developmental testing. The most detailed contemporary formal developmental data suggests that preterm birth in infants with gastroschisis may influence both cognitive and motor development.
Given the lack of definitive data, in addition to the lack of a compelling hypothesis that would suggest otherwise, we speculate that infants with gastroschisis who are born prematurely experience equal or worse outcomes, compared with preterm infants without this congenital anomaly. Thus, there is potential for benefit in delaying delivery in pregnancies that are affected by gastroschisis.
The developmental benefits of delaying delivery must be balanced with all other known risks and benefits. Some clinicians theorize that prolonged exposure to amniotic fluid increases bowel damage and dysmotility and therefore advocate for routine early delivery in pregnancies that are complicated by gastroschisis. One small cohort study showed decreased time to the initiation of feeding and decreased length of stay with planned cesarean section delivery at 34 weeks' gestation.
However, other retrospective studies report worse outcomes that are related to preterm delivery of neonates with gastroschisis, compared with term delivery. Boutros et al
described an inverse relationship between gestational age and ventilator days, time on parenteral nutrition, and length of stay. An additional small randomized controlled trial showed no difference in outcomes between elective delivery at 36 weeks' gestation compared with spontaneous labor
; however, the sample size may not have been sufficient to detect a difference because many pregnancies with gastroschisis will deliver spontaneously before term.
Results of this metaanalysis suggest a pooled prevalence of IUFD with gastroschisis of 4.48 per 100 births, which is much lower than previously cited but higher than the general population. The prevalence of IUFD did not increase during late gestation. The overall risk of IUFD is greatest at <36 weeks' gestation, which is earlier than many obstetricians would consider routine elective delivery. It appears that, once a fetus has completed 35 weeks' gestation, it already has assumed most of the risk of IUFD; therefore, fetal death should not weigh as heavily in the decision electively deliver early. However, we must point out that the methods used to generate our estimates of IUFD assume the denominator to be constant. Because of the high rate of early deliveries, this assumption limits our ability to calculate prospectively the risk for fetal death at advanced gestational ages. Furthermore, data regarding additional anomalies and comorbidities were provided only rarely in the reviewed articles. Therefore, we were unable to control for other extraneous factors that may have led to fetal death, such as abnormal karyotype, additional congenital anomalies, or other related factors such as intestinal dilation.
Our objective in evaluating the presence of a delivery plan was to determine whether having a clearly stated delivery process decreased the likelihood of death. We did not intend to evaluate the merits of any individual plan. The reported delivery plans differed greatly in both the antenatal monitoring and proposed goal for gestational age at delivery. Our results suggest that having a delivery plan (1) does not alter the rate of IUFD and (2) does not change the gestational age at delivery. The reason the delivery plan may not influence outcomes is that either the delivery plan is not adhered to or the studies in which no delivery plan is reported have a practice of early, elective delivery. We suspect that both of these possibilities contributed to our observations. Additional study of antenatal risk factors and comprehensive delivery plans may allow for individualized approaches to planning the timing of delivery. Identification of those pregnancies that would benefit from early delivery would optimize outcomes without compromising those who would not benefit.
We believe that multiple factors influence caregiver decisions regarding the timing of nonspontaneous deliveries that are affected by gastroschisis. The risk of ongoing visceral injury is a prominent concern. However, in the absence of specific compromise of bowel integrity (ie, dilation), there is not consistent evidence in the literature that supports the practice of routine early delivery to improve gut-related outcomes. In our experience, the risk for fetal death is the primary driver of early elective delivery. Misrepresentation of risk in the literature and anecdotal evidence play key roles in perpetuating this practice.
Our study also suggests that the gestational age at delivery for pregnancies that are affected by gastroschisis is decreasing over time. We speculate that, as prenatal diagnosis has become more common, the opportunity for obstetric intervention in the timing of delivery has increased. This likely has led to either an increase in elective early deliveries or an increase in indicated early deliveries. The role of each is impossible to determine based on the current literature. The causal relationship between earlier delivery and fetal or postnatal death is not clear. The role of fetal monitoring in the prevention of IUFD in gastroschisis is not well established. Most accounts of antenatal management in the published literature describe the inclusion of increased antenatal monitoring, which includes increased frequency of ultrasound scanning, tococardiography, and other measures of fetal well-being. Despite this medical practice, there is little evidence to suggest that antenatal monitoring improves survival or other neonatal outcomes in this population.
This may be because fetal death in gastroschisis is an acute event without preceding indicators.
Our study has certain limitations. First, our results may be influenced by early elective delivery that eliminated potential IUFDs. When we compared studies with and without an early elective delivery plan, we found no significant difference in outcomes of IUFD. However, this finding may be the result of improved prenatal monitoring practices. The use of ultrasound scanning and biophysical profiles to assess for the compromised fetus and the increased awareness of IUFD may contribute to overall fetal survival. Second, although the risk for IUFD has decreased, the postnatal mortality rate may have increased. We found a pooled prevalence of postnatal survival of 95%. These results are similar to those published by Vachharajani et al,
who reported a postnatal survival of approximately 90%. These improvements in postnatal survival most likely are related to the advances in total parental nutrition, surgical care, antibiotics, and tertiary neonatal intensive care units. Finally, our results may be influenced by ascertainment or referral bias. If referral bias were to be present, by concentrating the most severely affected pregnancies in tertiary care centers, our outcomes should be biased to overestimate the rate of IUFD. We attempted to limit this bias by including larger, population-based published cohorts. We cannot, however, account for gastroschisis cases that were not diagnosed before delivery.
This metaanalysis seeks to provide more evidence to consider in decision-making for the timing of the delivery in gastroschisis. Normal neonates without congenital defects are at a higher risk of morbidity and death when they are delivered prematurely, which has resulted in a trend in the United States to delay the timing of elective deliveries to >39 weeks' gestation. The risk of IUFD in gastroschisis is lower than is cited commonly; however, the implications of even a single potentially preventable death are significant. Given the small incremental increase in risk for IUFD with advancing gestational age, we advocate for strategies to delay elective delivery before term in the stable patient with gastroschisis. Elective delivery at >36 completed weeks' gestation may be an appropriate balance of risks and benefits. Given the lack of data regarding fetal death in the setting of in utero growth restriction or bowel dilation, we cannot advocate for changes in current management strategies. Although there is no strong evidence that antenatal fetal monitoring prevents IUFD in gastroschisis,
there may be a benefit to increased monitoring at ≥36 weeks' gestation, with a plan to deliver at 37 weeks' gestation. Antenatal markers that include cytokine profiles, oligohydramnios, and bowel dilation have been evaluated yet have not been shown to be predictive of outcomes in gastroschisis.
Throughout pregnancy, the pooled prevalence of IUFD in gastroschisis is 7-fold higher (4.48%) than that of the general population (0.62%). Furthermore, at >36 weeks' gestation, our data suggest that the risk for IUFD is still significantly higher than the general obstetric population, thus making the question of antenatal monitoring pertinent. The current paucity of data does not allow for early identification of individual infants who are likely to experience bad outcomes. Despite this, ultrasound findings that are consistent with increasing intraabdominal size or dilation may warrant earlier delivery because of risks of postnatal morbidity. Large, prospective, multicenter evaluations of prenatal risk factors for IUFD are needed, along with randomized trials that are designed to determine optimal timing of delivery in pregnancies that are affected by IUFD.
References
Castilla E.E.
Mastroiacovo P.
Orioli I.M.
Gastroschisis: international epidemiology and public health perspectives.
Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats. Available at: http://www.cdc.gov/nchs/vitalstats.htm. Accessed Aug. 21, 2012.
Is unexplained third trimester intrauterine death of fetuses with gastroschisis caused by umbilical cord compression due to acute extra-abdominal bowel dilatation?.
Canadian Pediatric Surgical Network: a population-based pediatric surgery network and database for analyzing surgical birth defects: the first 100 cases of gastroschisis.
Omphalocele and gastroschisis: prenatal diagnosis and peripartal management: a case analysis of the years 1989-1997 at the Department of Obstetrics and Gynecology, University of Homburg/Saar.
Sonographic assessment of the extra-abdominal fetal small bowel in gastroschisis: a retrospective longitudinal study in relation to prenatal complications.
This study was supported by the Perinatal Institute at Cincinnati Children's Hospital Medical Center , Cincinnati, OH.
The authors report no conflict of interest.
Cite this article as: South AP, Stutey KM, Meinzen-Derr J. Metaanalysis of the prevalence of intrauterine fetal death in gastroschisis. Am J Obstet Gynecol 2013;209:114.e1-13.
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