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Grand Rounds

Amnioexchange for Fetal Gastroschisis: Does it Reduce Morbidity?

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BACKGROUND AND PURPOSE:

  • Direct exposure of fetal bowel to amniotic fluid can trigger significant ischemic and inflammatory processes
  • Based on experiments in animals, an amnioexchange procedure may reduce inflammation
  • Luton et al. (BJOG, 2019) investigated the benefits of using this amnioexchange procedure for fetal gastroschisis in humans

METHODS:

  • Prospective, interventional, randomized study (RCT)
  • Participants
    • Pregnant women >18 years of age and ≥20 weeks gestation
    • Singleton pregnancy
    • Fetal gastroschisis (isolated)
  • Intervention (in utero)
    • Amnioexchange procedure
      • Started at 30 weeks q2weeks | 300 ml amniotic fluid removed via 18 gauge needle and same volume of saline replaced
    • A sham procedure
      • 1 ml saline injected subQ at the site and using a perfusion bag, sounds and movements were simulated similar to amnioexchange arm
  • In both arms
    • Patients draped in a way that they were blinded
    • Steroid injections at 30 weeks
    • Postnatal minimal enteral feeding
  • Primary outcome
    • A composite variable based on the duration of ventilation and parenteral nutrition
  • Secondary outcomes
    • Effectiveness and safety of the amnioexchange procedure, including
      • The rate of perinatal death
      • Time to full enteral feeding
      • Primary closure
      • Late feeding disorders

RESULTS:

  • Study stopped early, midway through recruitment due to
    • Failure to recruit sufficient cases
    • Failure at the last analysis to show any improvement in the amnioexchange arm
    • Concern about side effects
  • 64 patients were randomized
    • 34 in amnioexchange group | 30 in placebo group
  • Primary outcome
    • No difference in the composite criteria between groups
  • Secondary outcome
    • No significant between-group differences in pregnancy outcome or complications
  • There was a relationship between digestive enzymes and inflammation factors in the amniotic fluid
    • Bile acid levels are associated with both ferritin and interleukin 1β (IL1β); P < 0.01

CONCLUSION:

  • The amnioexchange protocol used in this study is not an option for fetal care in humans
  • Future gastroschisis research should focus on modalities to reduce inflammatory pathways

Learn More – Primary Sources:

A randomised controlled trial of amnioexchange for fetal gastroschisis

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Does Delivery Location Really Impact Gastroschisis Outcomes?
Practical obstetrics info for your women's healthcare practice
Gastroschisis – Detection and Implications

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