doi:10.1111/jog.13662 J. Obstet. Gynaecol. Res.

2018

Stomach herniation prior to nonreassuring fetal status in a

case of fetal gastroschisis

Yuki Kojima, Katsusuke Ozawa, Rika Sugibayashi, Seiji Wada and Haruhiko Sago
Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan

Abstract
The neonatal prognosis in gastroschisis is generally good; however, intrauterine fetal death (IUFD) and non-
reassuring fetal status (NRFS) sometimes occur in fetal cases of gastroschisis. Previously, we reported stom-
ach herniation as a possible risk factor for IUFD or NRFS in fetuses with gastroschisis. We report a case of
fetal gastroschisis showing stomach herniation and increased velocity of the umbilical venous (UV) flow the
day before NRFS by electronic fetal monitoring (EFM). A 27-year-old pregnant woman was followed up
from 16 weeks’ gestation due to fetal gastroschisis. At 33 + 1 weeks’ gestation, EFM displayed a reassuring
fetal state, while the ultrasound examination revealed fetal stomach herniation and an increased flow veloc-
ity of the UV in the abdomen. One day later, EFM displayed NRFS, and the patient underwent emergency
caesarean section. This case showed stomach herniation preceding the occurrence of NRFS. Stomach hernia-
tion may be a predictor of NRFS in fetuses with gastroschisis.
Key words: fetal death, gastroschisis, nonreassuring fetal status, stomach herniation, velocity of umbilical
venous flow.

Introduction with gastroschisis.5 Here, we here report a case of

Gastroschisis is an abdominal wall defect and a seri-
ous congenital anomaly requiring neonatal surgery as
the fetal intestinal tract extending from the wall defect
gradually expands in utero. The incidence of gastro-
schisis is reported to be 2–5 per 10 000 births. There
have been several reports on ultrasound findings,
such as bowel dilatation, associated with the postnatal
outcome in fetuses with gastroschisis.1–3 Although
neonatal prognosis is generally good, intrauterine
fetal death (IUFD) and nonreassuring fetal status
(NRFS) sometimes occur. South et al.4 reported that
waiting until 37 weeks’ gestation for delivery
increased the risk of IUFD in fetuses with gastroschi-
sis. However, it is unclear which prenatal findings
best predict IUFD and NRFS in fetuses with
gastroschisis.
We previously reported that stomach herniation is
a possible risk factor for IUFD or NRFS in fetuses
fetal gastroschisis that showed stomach herniation
and increased velocity of the umbilical venous
(UV) flow by electronic fetal monitoring (EFM) the
day before NRFS.
Case Report
A 27-year-old woman (gravida 1, para 0) was referred
to our hospital due to fetal gastroschisis at 16 weeks’
gestation. She did not smoke or drink alcohol. Our ini-
tial ultrasound scan at 16 weeks’ gestation revealed gas-
troschisis with an echogenic mass (26 × 10 × 12 mm)
protruding from the anterior abdomen wall. The mass
was on the right side of the annulus umbilical, and the
stomach and liver were inside of the abdomen (Fig. 1a).
No other fetal morphological anomalies were found.
Serial ultrasound examinations were carried out every
2 weeks until 31 weeks’ gestation and every week

Received: August 4 2017.

Accepted: March 23 2018.
Correspondence: Dr Haruhiko Sago, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child
Health and Development, 2-10-1 Okura, Setagaya, Tokyo 157-8535, Japan. Tel.: +81-3-3416-0181, Email: sagou-h@ncchd.go.jp

© 2018 Japan Society of Obstetrics and Gynecology 1

Y. Kojima et al.

Figure 1 Ultrasound images. (a) Extra-abdominal intestine (circle) and stomach in the abdomen (arrow) of the fetus at
20 weeks’ gestation. (b) Stomach in the fetal abdomen (arrow head) at 32 weeks’ gestation. (c) Stomach herniated from
the fetal abdomen at 33 + 1 weeks’ gestation (arrow).

thereafter (Table 1). A routine fetal ultrasound examina-
tion showed a dilated extra-abdominal intestine at
25 weeks’ gestation, so we measured the inner diameter
and wall thickness of the extra-abdominal intestine. We
also measured the blood flow pattern in the umbilical
artery (UA) and the velocity of the UV flow inside of
the fetal abdomen using a Doppler examination from
23 weeks’ gestation onward. EFM was performed from
33 weeks’ gestation onward.
The fetal stomach was in the abdomen at 32 weeks’
gestation (Fig. 1b). However, an ultrasound examina-
tion showed fetal stomach herniation (Fig. 1c) and
increased velocity of the UV flow inside of the fetal
abdomen (70.9 cm/s; the 5th and 95th percentiles of
the velocity of UV flow were 14.9 and 40.9 cm/s,
respectively6) and oligohydramnios at 33 + 1 weeks’
gestation. EFM displayed a reassuring fetal state
(Fig. 2a). However, the next day (at 33 + 2 weeks’
gestation), EFM showed a basal heart rate of 160 beats
per minute and reduced accelerations and baseline
variability (Fig. 2b). After 5 h, EFM displayed a basal
heart rate of 170 beats per minute (tachycardia) with
reduced baseline variability (Fig. 2c), which was a
sign of NRFS, as defined by the Japanese intrapartum
management guidelines.7 We therefore chose prompt
delivery and performed emergency caesarean section.
A female infant weighing 1630 g with Apgar scores
of 8 and 9 after 1 and 5 min, respectively, was deliv-
ered. We failed to collect a blood sample from the
umbilical artery due to its collapse; the infant venous
blood pH was 7.360, and the base excess was 0.3. The
amniotic fluid was turbid, with yellow–brown matter
floating in it. The infant was admitted to the neonatal
intensive care unit. An abdominal wall defect was
confirmed, with the dilated intestine protruding
through it. A physical examination revealed no other
anomalies. The dilated intestine was swollen and
inflamed by amniotic fluid, but there were no findings

Table 1 Fetal ultrasound findings

16w1d 18w1d 20w1d 23w1d 25w4d 27w4d 29w1d 31w1d 32w1d 33w1d
BPD (mm) 36.3 41.7 48.9 55.3 63.2 65.9 70.3 76.0 77.9 76.5
SD† 1.1 0.5 0.7 −0.3 0 −0.9 −0.8 −0.3 −0.6 −1.5
AC (cm) 9.2 11.8 13.0 15.2 16.5 18.5 19.9 20.7 20.7 19.9
SD † −1.5 −0.8 −1.4 −1.9 −2.5 −2.3 −2.3 −2.6 −3.2 −4.0
FL (mm) 19.2 27.4 31.4 37.1 43.6 45.7 47.7 54.0 55.5 54.3
SD † −0.5 0.6 0.2 −0.4 −0.1 −0.9 −0.6 −0.6 −0.8 −1.7
MVP (cm) 4.3 5.2 4.0 3.2 3.6 3.1 4.1 4.6 3.2 1.9
Dilated extra- ― ― ― ― 0.5 0.8 0.8 1.1 1.2 1.3
abdominal bowel
(cm)
Bowel wall thickness ― ― ― ― 1.7 ― 1.8 ― 1.5 2.0
(mm)
Velocity of umbilical ― ― ― 19.4 14.6 23.4 ― 23.8 ― 70.9
venous flow
(cm/s)
†SD was calculated using the formula of the Japanese Society of Ultrasound in Medicine. AC, abdominal circumference; BPD, biparietal
diameter; d, days; FL, femur length; MVP, maximum vertical pocket; SD, standard deviation; w, weeks.

2 © 2018 Japan Society of Obstetrics and Gynecology


Figure 2 Electronic fetal
monitoring (EFM). (a)
EFM on admission. (b)
EFM in the morning at
33 + 2 weeks’ gestation.
(c) EFM in the afternoon at
33 + 2 weeks’ gestation.
of intestinal atresia or necrosis. The infant received a
silo placement at 5 h after delivery. Primary closure of
the defect was performed at 6 days of age. Oral feed-
ing with mother’s milk started at 9 days of age, and
the infant left the hospital at 57 days of age.
Discussion
We detected stomach herniation and an increased
velocity of the UV flow the day before NRFS. This
© 2018 Japan Society of Obstetrics and Gynecology
Stomach herniation in gastroschisis
case showed that stomach herniation and increased
UV flow velocity preceded the NRFS in a fetus with
gastroschisis.
We previously reported that ultrasound findings of
stomach herniation increased the risk of IUFD or
NRFS in fetal gastroschisis.5 Antonio et al.8 reported
that gastric dilatation was associated with neonatal
death in their meta-analysis. Sinkey et al.9 reported
that an ultrasound finding associated with perinatal
loss was an abnormal stomach location, including
stomach herniation before delivery. These stomach
3
Y. Kojima et al.
findings, which suggest compression of the umbilical
cord, may be associated with deterioration of the fetal
well-being. Our case suggested that stomach hernia-
tion might precede the occurrence of NRFS in fetuses
with gastroschisis.
Increased velocity of the UV flow inside the fetal
abdomen was detected before fetal tachycardia in our
case. There have been some reports of a relationship
between the flow pattern of the umbilical artery and
fetal distress. In a previous report, a notch in the UA
flow was found on a Doppler examination with NRFS
on the EFM.10 We observed no significant changes in
the UA flow over the course of the pregnancy in our
case; instead, the velocity of the UV flow increased. This
may be because (i) the UV was more susceptible to the
effect of pressure than the UA, (ii) UV flow velocity
might have increased due to compression of the UV
inside the abdomen by stomach herniation or (iii) fetal
tachycardia may have been caused by hypovolemia
due to pressure on the UV by stomach herniation.
The dilatation and the wall thickness of the extra-
abdominal intestine gradually progressed but were
not severe in our case, and the intestine of the new-
born was in good condition. A previous study
showed a relationship between the dilated extra-
abdominal intestine in the fetus and bowel disorder
in the newborn, such as intestinal disabilities and nec-
rotizing enterocolitis needing enterectomy.9 Brown
et al.11 reported that there was no relationship
between NRFS and the severity of extra-abdominal
bowel dilatation. Durfee et al.12 reported that bowel
dilatation developed in 72 of 84 cases (86%), and
bowel wall thickness developed in 40 of 73 cases
(55%), although there was no relationship between
bowel dilatation or wall thickness in the fetus and the
survival of fetuses and newborns with gastroschisis.
We therefore believe that there is still room for discus-
sion about the relationship between extra-abdominal
intestinal findings and the survival of fetuses or new-
borns with gastroschisis.
Fetuses with gastroschisis are at risk of fetal distress
and IUFD. Our case showed that fetal stomach herni-
ation is associated with an increased velocity of the
UV flow preceding NRFS. This suggests the impor-
tance of management with a combination of ultra-
sound and EFM to prevent fetal distress and IUFD in
cases of gastroschisis. Further studies should explore
the relationship between ultrasound findings, such as
4 © 2018 Japan Society of Obstetrics and Gynecology
fetal stomach herniation and abnormal UV Doppler
findings, and the outcomes of newborns in cases of
fetal gastroschisis.
Disclosure
None declared.
References
1. Santiago-Munoz PC, McIntire DD, Barber RG, Megison SM,
Twickler DW, Dashe JS. Outcomes of pregnancies with fetal
gastroschisis. Obstet Gynecol 2007; 110: 663–668.
2. Long AM, Court J, Morabito A, Gillham JC. Antenatal
diagnosis of bowel dilatation in gastroschisis is predictive
of poor postnatal outcome. J Pediatr Surg 2011; 46:
1070–1075.
3. Robertson JA, Kimble RM, Stockton K, Sekar R. Antenatal
ultrasound features in fetuses with gastroschisis and its pre-
diction in neonatal outcome. Aust N Z J Obstet Gynecol 2017;
57: 52–56.
4. South AP, Stutey KM, Derr JM. Metaanalysis of the preva-
lence of intrauterine fetal death in gastroschisis. Am J Obstet
Gynecol 2013; 209: 114.e1–114.e13.
5. Kanda E, Ogawa K, Sugibayashi R et al. Stomach hernia-
tion predict fetal death or non-reassuring fetal status in
gastroschisis at late pregnancy. Prenat Diagn 2013; 33:
1302–1304.
6. Acharya G, Wilsgaard T, Berntsen GKR, Maltau JM,
Kiserud T. Reference ranges for umbilical vein blood flow in
the second half of pregnancy based on longitudinal data.
Prenat Diagn 2005; 25: 99–111.
7. Okai T, Ikeda T, Kawarabayashi T et al. Intrapartum man-
agement guidelines based on fetal heart rate pattern classifi-
cation. J Obstet Gynecol Res 2010; 36: 925–928.
8. Antonio FD, Virgone C, Rizzo G et al. Prenatal risk factors
and outcomes in gastroschisis: A meta-analysis. Pediatrics
2015; 136: e159–e169.
9. Sinkey RG, Habli MA, South AP et al. Sonographic markers
associated with adverse neonatal outcomes among fetuses
with gastroschisis: An 11-year, single-center review.
Am J Obstet Gynecol 2016; 214: 275.e1–275.e7.
10. Kalache KD, Bierlich A, Hammer H, Bollmann R. Is unex-
plained third trimester intrauterine death of fetuses with
gastroschisis caused by umbilical cord compression due to
acute extra-abdominal bowel dilatation? Prenat Diagn 2002;
22: 715–717.
11. Brown N, Nardi M, Greer RM et al. Prenatal extra-
abdominal bowel dilatation is a risk factor for intrapartum
fetal compromise for fetuses with gastroschisis. Prenat Diagn
2015; 35: 529–533.
12. Durfee SM, Benson CB, Adams SR et al. Postnatal outcome
of fetuses with the prenatal diagnosis of gastroschisis. J
Ultrasound Med 2013; 32: 407–412.