What Is the Circumferwnce if a Babies Esophagus
Geburtshilfe Frauenheilkd. 2015 November; 75(eleven): 1148–1152.
Language: English | High german
Measurement of Gastric Circumference in Foetuses with Oesophageal Atresia
Messung des Magenumfangs bei Feten mit Ösophagusatresie
M. Hoopmann
aneDepartment of Obstetrics and Gynecology, University of Tübingen, Tübingen
K. O. Kagan
1Department of Obstetrics and Gynecology, University of Tübingen, Tübingen
F. Borgmeier
1Department of Obstetrics and Gynecology, University of Tübingen, Tübingen
Yard. Seitz
2Section of Pediatric Surgery and Urology, University Childrenʼs Hospital, Tübingen
J. Arand
iiiDepartment of Neonatology, University Childrenʼs Hospital, Tübingen
P. Wagner
aneSection of Obstetrics and Gynecology, University of Tübingen, Tübingen
Received 2015 Jul 18; Revised 2015 Aug 23; Accepted 2015 Aug 25.
Abstract
Groundwork: The specific recognition of oesophageal atresia (OA) with or without a tracheal fistula in a foetus is a diagnostic challenge for prenatal medicine. The aim of the present work is to analyse the value of the measurement of gastric size in the diagnosis of this significant malformation. Materials and Methods: Birthday, the examinations of 433 pregnancies between the xviii.4 and 39.ane weeks of gestation were retrospectively analysed. 59 of these foetuses exhibited an OA. By means of a linear regression analysis with normal foetuses, significant parameters influencing gastric size were examined. Subsequently the gastric sizes were transformed into z values and a comparison was made between OA with and without fistulae with the help of t tests. Results: In the normal foetuses there was a pregnant clan between the gastric circumference and the abdominal circumference (circumference = 6.809 + 0.179 × abdominal circumference, r = 0.686, p < 0.0001). In the normal group the average was 43.0 (standard deviation [SD] thirteen.seven) mm and those in foetuses with and without fistuale were 33.8 (SD 22.7) and 0.9 (SD 3.seven) mm. In 34 (57.6 %) foetuses with an OA, the gastric circumference was beneath the 5th percentile. In detail, at that place were 13 (34.2 %) foetuses with a fistula and 21 (100 %) without a fistula. The average z values in the normal group and in the groups of OA with fistula and without fistula amounted to 0.0 (SD 1.0), −1.three (SD 2.two) and −four.5 (SD 1.0). Conclusion: Measurements of the gastric circumference below the 5th percentile should pb to further diagnostic measures, peculiarly when associated with polyhydramnios. Although OA without a fistula is always conspicuous, only about ane in three OAs with fistula are associated with a significantly smaller stomach.
Key words: gastric circumference, oesophageal atresia, tracheo-oesophageal fistula
Abstract
Zusammenfassung
Fragestellung: Dice gezielte Erkennung einer fetalen Ösophagusatresie (ÖA) mit oder ohne tracheale Fisteln stellt eine diagnostische Herausforderung für dice Pränatalmedizin dar. Ziel der vorliegenden Arbeit war es, den Stellenwert der Messung des Magenumfangs für die Diagnostik dieser bedeutsamen Fehlbildung zu analysieren. Cloth und Methodik: Insgesamt wurden die Untersuchungen von 433 Schwangerschaften zwischen der 18,4 bis 39,i Schwangerschaftswoche retrospektiv ausgewertet. 59 dieser Feten wiesen eine ÖA auf. Mittels linearer Regressionsanalyse wurden bei normalen Feten signifikante Einflussparameter auf den Magenumfang untersucht. Anschließend erfolgte die Umwandlung der Magenumfänge in z-Werte und der Vergleich zwischen den ÖA mit und ohne Fistel mit der Normalpopulation mithilfe eines t-Tests. Ergebnisse: Bei den normalen Feten zeigte sich eine signifikante Assoziation zwischen dem Umfang des Magens und dem Abdomenumfang (Umfang = 6,809 + 0,179 × Abdomenumfang, r = 0,686, p < 0,0001). Der mittlere Magenumfang lag in der normalen Gruppe bei 43,0 (Standardabweichung [STW] thirteen,vii) mm und bei Feten mit und ohne Fistel bei 33,8 (STW 22,seven) und 0,nine (STW 3,7) mm. Bei 34 (57,half dozen %) Feten mit einer ÖA lag der Magenumfang < 5er-Perzentile. Im Einzelnen waren es xiii (34,2 %) Feten mit einer Fistel und 21 (100 %) ohne Fistel. Die mittleren z-Werte in der normalen Gruppe und in der Gruppe der ÖA mit Fistel und ohne Fistel lagen bei 0,0 (STW 1,0), −1,3 (STW two,ii) und −4,five (STW 1,0). Schlussfolgerung: Messungen des Magenumfangs < 5er-Perzentile sollten eine weiterführende Diagnostik nach sich ziehen. Während ÖA ohne Fisteln hierbei stets auffällig werden, weist nur ungefähr jede 3. ÖA mit Fistel einen signifikant verkleinerten Magen auf.
Schlüsselwörter: Magenumfang, Ösophagusatresie, tracheoösophageale Fistel
Introduction
During the fifth to sixth week of embryonal development the oesophagus and trachea separate from a common anlage within the early intestinal tube. An incomplete separation leads to the congenital malformation of oesophageal atresia (OA). In the majority of the cases (72–xc %) the trachea is also involved in the form of a tracheo-oesophageal fistula between the lower department of the trachea and the oesophagus. The prevalence varies from region to region and is estimated to amount to an average of 2.43 to 2.86 cases per ten 000 births 1, 2, iii. A large proportion of the afflicted infants too exhibit further malformations or syndromes (such as, e.grand., VACTERL association, trisomy 18, Accuse syndrome). The near frequent associated malformation is congenital centre disease. In current reports of the EUROCAT Annals only 44.vii % of the cases are isolated findings one. Beside the associated malformations, the regular occurrence of preterm births represents a significant prognostic gene. Because of the frequent occurrence of polyhydramnios, premature commitment ensues in 38.v % of the cases i, 4, v. Survival rates of near 100 % can exist expected in isolated cases with adequate prenatal and neonatal management vi, 7, 8. Later complications and morbidities during babyhood consist of swallowing difficulties on account of narrow anastomoses or gastro-oesophageal reflux besides as recurring infections 9, 10, 11.
The electric current data situation is contradictory with regard to benefits for the afflicted babies resulting from prenatal diagnosis. Whereas, for example, Brantberg and co-workers demonstrated a significantly amend survival (100 vs. 73 %) for cases identified prior to birth, other groups institute a poorer prognosis for this collective 12, 13. The latter can be explained by the over-representation of OA without fistulas and associated malformations in the group of prenatally detected cases. However, current opinion is that prenatal diagnosis must be considered as a do good in that information technology provides a possibility for prenatal counselling of the parents and a reduction of postpartum transfers 14.
The existing detection rates within Europe vary between less than x % to more than than 50 % (on average 36.5 %) 1, 15. Sonographic visualisation of the oesophagus stretches fifty-fifty modernistic ultrasound systems to the limits of their resolution. In cases without a fistula the inability to visualise gastric filling leads to the diagnosis 16. Cases with fistulas are not and then frequently detected prenatally. Although a small stomach has been described by many groups every bit a sign, in that location is more often than not a lack of an objectifiable limiting value for gastric size xiii. The aim of the nowadays study is to examine the gastric size equally a potential diagnostic criterium for foetuses with OA not only with but also without tracheo-oesophageal fistulas.
Material and Methods
The underlying investigations were carried out in the Department of Prenatal Medicine of the University Infirmary Tübingen and findings were assessed retrospectively.
Measurement methods
Offset of all the digitally saved images for gastric circumference measurements of routinely performed biometric examinations were examined. A prerequisite was the articulate demonstration of the anatomic landmarks spinal column cross-section, parallel sections of rib pairs, the full tummy and the proximal office of the umbilical vein and its transition to the ductus venosus and to the right portal vein. The gastric filling was always measured in the biometry aeroplane. For this the gastric circumference was adamant manually on the digitally saved images (Fig. 1).
Illustration of the measurement of gastric circumference by manual tracing of the gastric circumference in the biometry plane.
Collective
To obtain an average value for the circumference, values from 374 normal singleton pregnancies were considered. The test collective consisted of 59 pregnant women in whom there was evidence for foetal OA.
In pregnancies with conspicuous foetuses the first examination undertaken in the Gynaecology Department of Tübingen University Infirmary was considered in each case.
Registration of associated influencing factors
Beside the gastric circumference, we likewise recorded the caput circumference, the abdominal circumference, the femur length as well as the gestational age at the fourth dimension of the examination. Furthermore, the existance of polyhydramnios, defined as the largest vertical amniotic fluid depot over 8 cm, equally well as performance of relief drainage measures were recorded.
Statistical Analysis
In normal foetuses significant factors influencing the gastric circumference were investigated by linear regression assay. After the gastric circumference was transformed to a z value and comparisons betwixt foetuses with OA with and without fistula and the normal population were fabricated with the help of t tests. Differences with a p value < 0.05 were considered to be pregnant.
The results are given equally median (range) or average (standard deviation SD) values.
Approval of upstanding commission
Because of the retrospective anonymized character of our study, an approval of the local ethical committee was non necessary. However, the ethical committee was informed about the study (IEC number: 597/2015R).
Results
Characteristics of the enrolled meaning women
Altogether 433 patients were included in the evaluation. The median body weight amounted to 62.3 kg (range 45.0–163.0 kg). The median gestational age was 23.3 weeks (range eighteen + ii–39 + one weeks) whereby 261 (threescore.iii %) were seen before the 26 + 0 week and 172 (39.7 %) thereafter.
Distribution of foetuses with oesophageal atresia and gastric circumference
OA was present in 59 (13.7 %) of the 433 foetuses. Of these 38 (64.4 %) foetuses had OA with and 21 (35.vi %) OA without a tracheo-oesophageal fistula. Also twenty (33.nine %) of the foetuses had a chromosomal disorder, the proportions in the OA groups with and without a fistula were 23.vii and 52.4 %, respectively. xiv (36.viii %) of the foetuses with OA and a fistula as well had a polyhydramnios. Among the group of foetuses with OA only without a fistula polyhydramnios was diagnosed in 12 (57.i %) of them.
For 21 of the foetuses no stomach could be observed during the entire test menstruation. Of these 20 (95.2 %) had an OA without fistula. In these cases the gastric circumference was ready at 0.i mm. The average gastric circumference in the normal grouping amounted to 43.0 mm (SD 13.7 mm) and in foetuses with and without fistula to 33.8 mm (SD 22.vii mm) and 0.9 mm (SD 3.vii mm).
Association of gastric circumference with other factors
In the normal foetuses at that place was a pregnant association between gastric circumference and abdominal circumference (circumference = vi.809 + 0.179 × abdominal circumference, r = 0.686, p < 0.0001). In addition significant correlations with gestational age (r = 0.669, p < 0.0001), caput circumference (r = 0.659, p < 0.0001) and femur length (r = 0.671, p < 0.001) were observed. The association with abdominal circumference was used for the further analyses.
Percentile and z values
In 18 (4.8 %) of 374 normal patients the gastric circumference of the foetus was below the 5th percentile. In dissimilarity this was the example with 34 (57.half-dozen %) of the foetuses with OA. In detail, at that place were 13 (34.ii %) foetuses with a fistula and 21 (100 %) without a fistula (Fig. 2).
Graphic presentation of the normal distribution of gastric circumference in dependence on abdominal circumference including the fifth and 95th percentiles. The points prove the gastric circumference values of foetuses with OA (red dots with fistula, orange dots without fistula).
The boilerplate z values in the normal group and in the OA groups with and without fistula amounted to 0.0 (SD 1.0), −i.three (SD 2.2) and −4.v (SD 1,0) (t test: OA with fistula vs. normal p = 0.001; t test: OA without fistula vs. normal p < 0.001; t test: OA with fistula vs. OA without fistula p < 0.0001) (Fig. iii).
Boxplots of the z values for gastric circumference in the normal population, in foetuses with OA and fistulas and in foetuses with OA without fistulas.
Discussion
The nowadays study has shown that the average gastric size, measured as gastric circumference at the level of the abdominal biometric plane is reduced not just in foetuses with OA and fistula but too in foetuses with OA but without fistula. In all cases without fistulas a completely or almost completely empty breadbasket was seen. The combination of a non-visualisable or very small tummy with polyhydramnios is a well known sign for the presence of an oesophageal obstruction 15, 17, xviii. However, the appreciable false positive rates and the frequently subjective evaluation of gastric filling demand to be taken into consideration four, 19. Attempts to improve the prenatal detection rates concentrate on the prenatal visualisation of the oesophageal pouch sign that occurs through dilatation of the blind-ending proximal segment of the oesophagus 20, 21. But, in well-nigh cases, the OA results in this pathognomic bullheaded sack being missed due to the fistula. In improver, the pouch sign can besides exist seen as a temporary transient finding in structurally inconspicuous foetuses, so that simulated positive findings are recorded 22.
Recognition of the majority of cases of OA with fistula represents the central problem. Impairments of foetal swallowing in such cases depend on the lumen of the tracheo-oesophageal fistula. In cases with big fistulas even the occurrence of polyhydramnios may be lacking. The sensitivity of polyhydramnios alone amounts to merely 73 % in some studies 13. In combination with the criterion of a modest breadbasket at least a positive predictive value of upwards to 67 % tin can exist expected 13. In our collective there was a comparatively low charge per unit of polyhydramnios. Merely 36.8 % of the foetuses with OA and a fistula and 57.i % of the foetuses with OA without a fistula exhibited polyhydramnios. The reason for this is to be seen in the high proportion of severe chromosomal disorders of 33.9 % that in most cases led to an early termination of the pregnancy and the stronger weighting in the second trimester. Polyhydramnios develops in the course of the pregnancy to an always increasing extent and is thus by and large to be institute for the starting time time in an obvious degree in the 3rd trimester.
In many studies the assessment of gastric filling was purely subjective. An objective measurement by ways of a standardised gastric circumference appears to exist more reasonable in such cases. With the present study we have shown that the gastric size in at least 36.eight % of the afflicted foetuses with fistulas lies below the 5th percentile. Accordingly, the detection of a pocket-size stomach is a sign for farther detailed diagnostic work-upward.
The direct visualisation of the oesophagus either by means of loftier resolution second or 3D sonography or also by magnetic resonance imaging is extremely difficult and fourth dimension-consuming 23, 24. In isolated case reports, the direct prenatal sit-in has been realised past concentration on the surface area between the aorta and the trachea 25. If detection of the pouch sign is successful its predictive value must be assessed as being high. In some studies the value not only for sonography just also for foetal MRI has been 100 %, while other studies refer to the possibility of false positive findings 19, 22, 26. This shows that even though a detailed sonographic examination of the oesophagus is technically possible, the method cannot exist applied for unselected routine screening. Measurement of the gastric size tin can be helpful here since the presence of a small stomach can define a run a risk group for which a detailed examination of the oesophagus is required.
A further comeback in the diagnostics can be expected from the apply of 3D sonography 27. However, use of the published normal values of 3-dimensional biometry is at present limited due to the big discrepancies and the lack of methodological standardisation 28.
In very contempo studies an approach involving biochemical analysis of the amniotic fluid has been described. Here, unchanged values with regard to 50-leucine aminopeptidase (AMP) and elevated concentrations of alpha-foetoprotein (AFP) and gamma-glutamyl transpeptidase (GGT) are expected and so that especially the quotient from both concentrations has exhibited very practiced sensitivities and specificities in the first studies (98 %/100 %) 29, xxx. The currently available studies, however, are based on very small example numbers and require confirmation by larger trials. Furthermore, this is not suitable as a screening procedure due to its invasiveness and the thus associated interventional risks.
A limitation of the present study is its retrospective character and the thus associated lack of consideration of the dynamics of gastric filling. The latter are not abiding and are field of study to foetal swallowing cycles 31. However, this limitation holds for all included pregnancies and thus equally for the recorded gastric sizes of the afflicted foetuses as well as those of the normal population.
Practical Conclusions
The gastric size in foetuses with OA is reduced in cases with complete obstacle of the oesophagus. We have shown that reduced gastric filling below the fifth percentile is likewise found in 36.8 % of the foetuses with tracheo-oesophageal fistulas. Accordingly the measurement of gastric size tin define a gamble group requiring extensive further diagnostic work-up of the oesophagus.
Footnotes
Conflict of Interest None.
Supporting Information
References
1. Pedersen R Northward, Calzolari E, Husby South. et al.Oesophageal atresia: prevalence, prenatal diagnosis and associated anomalies in 23 European regions. Arch Dis Child. 2012;97:227–232. [PubMed] [Google Scholar]
2. Depaepe A, Dolk H, Lechat One thousand F. The epidemiology of tracheo-oesophageal fistula and oesophageal atresia in Europe. EUROCAT Working Group. Curvation Dis Kid. 1993;68:743–748. [PMC free article] [PubMed] [Google Scholar]
3. Forrester Grand B, Merz R D. Epidemiology of oesophageal atresia and tracheo-oesophageal fistula in Hawaii, 1986–2000. Public Health. 2005;119:483–488. [PubMed] [Google Scholar]
4. Abele H, Starz S, Hoopmann M. et al.Idiopathic polyhydramnios and postnatal abnormalities. Fetal Diagn Ther. 2012;32:251–255. [PubMed] [Google Scholar]
five. de Jong E M, de Haan M A, Gischler S J. et al.Pre- and postnatal diagnosis and outcome of fetuses and neonates with esophageal atresia and tracheoesophageal fistula. Prenat Diagn. 2010;30:274–279. [PubMed] [Google Scholar]
6. Deurloo J A, Ekkelkamp Due south, Schoorl G. et al.Esophageal atresia: Historical development of direction and results in 371 patients. Ann Thorac Surg. 2002;73:267–272. [PubMed] [Google Scholar]
seven. Konkin D E, Oʼhali West A, Webber E M. et al.Outcomes in esophageal atresia and tracheoesophageal fistula. J Pediatr Surg. 2003;38:1726–1729. [PubMed] [Google Scholar]
8. Lilja H East, Wester T. Consequence in neonates with esophageal atresia treated over the last 20 years. Pediatr Surg Int. 2008;24:531–536. [PubMed] [Google Scholar]
nine. Little D C, Rescorla F J, Grosfeld J Fifty. et al.Long-term analysis of children with esophageal atresia and tracheoesophageal fistula. J Pediatr Surg. 2003;38:852–856. [PubMed] [Google Scholar]
10. Chetcuti P, Phelan P D. Gastrointestinal morbidity and growth after repair of oesophageal atresia and tracheo-oesophageal fistula. Arch Dis Child. 1993;68:163–166. [PMC free commodity] [PubMed] [Google Scholar]
11. Chetcuti P, Phelan P D. Respiratory morbidity after repair of oesophageal atresia and tracheo-oesophageal fistula. Arch Dis Child. 1993;68:167–170. [PMC free article] [PubMed] [Google Scholar]
12. Brantberg A, Blaas H Grand, Haugen S E. et al.Esophageal obstruction-prenatal detection rate and effect. Ultrasound Obstet Gynecol. 2007;30:180–187. [PubMed] [Google Scholar]
13. Kunisaki S Thousand, Bruch South Due west, Hirschl R B. et al.The diagnosis of fetal esophageal atresia and its implications on perinatal outcome. Pediatr Surg Int. 2014;30:971–977. [PubMed] [Google Scholar]
14. Garabedian C, Sfeir R, Langlois C. et al.Does prenatal diagnosis alter neonatal handling and early outcome of children with esophageal atresia? Am J Obstet Gynecol. 2015;212:3400–iii.4E9. [PubMed] [Google Scholar]
fifteen. Houben C H, Curry J I. Current status of prenatal diagnosis, operative management and outcome of esophageal atresia/tracheo-esophageal fistula. Prenat Diagn. 2008;28:667–675. [PubMed] [Google Scholar]
16. Sase M, Asada H, Okuda M. et al.Fetal gastric size in normal and abnormal pregnancies. Ultrasound Obstet Gynecol. 2002;19:467–470. [PubMed] [Google Scholar]
17. Choudhry M, Boyd P A, Chamberlain P F. et al.Prenatal diagnosis of tracheo-oesophageal fistula and oesophageal atresia. Prenat Diagn. 2007;27:608–610. [PubMed] [Google Scholar]
18. Stringer M D, McKenna Yard M, Goldstein R B. et al.Prenatal diagnosis of esophageal atresia. J Pediatr Surg. 1995;30:1258–1263. [PubMed] [Google Scholar]
xix. Ethun C G, Fallon S C, Cassady C I. et al.Fetal MRI improves diagnostic accuracy in patients referred to a fetal center for suspected esophageal atresia. J Pediatr Surg. 2014;49:712–715. [PubMed] [Google Scholar]
twenty. Kalache Thousand D, Wauer R, Mau H. et al.Prognostic significance of the pouch sign in fetuses with prenatally diagnosed esophageal atresia. Am J Obstet Gynecol. 2000;182:978–981. [PubMed] [Google Scholar]
21. Yagel S, Sonigo P, Rousseau V. et al.Esophageal atresia diagnosed with iii-dimensional ultrasonography. Ultrasound Obstet Gynecol. 2005;26:307–308. [PubMed] [Google Scholar]
22. Solt I, Rotmensch S, Bronshtein M. The esophageal "pouch sign": a benign transient finding. Prenat Diagn. 2010;30:845–848. [PubMed] [Google Scholar]
23. Brugger P C, Weber M, Prayer D. Magnetic resonance imaging of the normal fetal esophagus. Ultrasound Obstet Gynecol. 2011;38:568–574. [PubMed] [Google Scholar]
24. Malinger One thousand, Levine A, Rotmensch S. The fetal esophagus: anatomical and physiological ultrasonographic characterization using a loftier-resolution linear transducer. Ultrasound Obstet Gynecol. 2004;24:500–505. [PubMed] [Google Scholar]
25. Develay-Morice J-E, Rathat G, Duyme M. et al.Ultrasonography of fetal esophagus: healthy appearance and prenatal diagnosis of a case of esophagus atresia with esotracheal fistula. Gynecol Obstet Fertil. 2007;35:249–257. [PubMed] [Google Scholar]
26. Garabedian C, Verpillat P, Czerkiewicz I. et al.Does a combination of ultrasound, MRI, and biochemical amniotic fluid analysis amend prenatal diagnosis of esophageal atresia? Prenat Diagn. 2014;34:839–842. [PubMed] [Google Scholar]
27. Kusanovic J P, Nien J Yard, Gonçalves Fifty F. et al.The apply of inversion mode and 3D manual sectionalization in book measurement of fetal fluid-filled structures: comparison with Virtual Organ Computer-aided AnaLysis (Song) Ultrasound Obstet Gynecol. 2008;31:177–186. [PMC gratis commodity] [PubMed] [Google Scholar]
28. Ioannou C, Sarris I, Salomon L J. et al.A review of fetal volumetry: the need for standardization and definitions in measurement methodology. Ultrasound Obstet Gynecol. 2011;38:613–619. [PubMed] [Google Scholar]
29. Czerkiewicz I, Dreux S, Beckmezian A. et al.Biochemical amniotic fluid pattern for prenatal diagnosis of esophageal atresia. Pediatr Res. 2011;70:199–202. [PubMed] [Google Scholar]
xxx. Muller C, Czerkiewicz I, Guimiot F. et al.Specific biochemical amniotic fluid design of fetal isolated esophageal atresia. Pediatr Res. 2013;74:601–605. [PubMed] [Google Scholar]
31. Sase 1000, Miwa I, Sumie K. et al.Gastric emptying cycles in the man fetus. Am J Obstet Gynecol. 2005;193:1000–1004. [PubMed] [Google Scholar]
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4678048/
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