Influence of Maternal Factors on Health

Outcomes in Gastroschisis:
A Canadian Population-Based Study
Imam Adli (030.10.132)
Dhika Claresta (030.09.068)

INTRODUCTION
Canada has seen an increased incidence of gastroschisis over

the last 2 decades to approximately 1 per 2,000 live births

The increasing incidence of gastroschisis worldwide has

encouraged researchers to reexamine the epidemiology of this

condition
The etiology of gastroschisis is unclear, but there are maternal

factors strongly associated with its development which may

also be associated with worse neonatal outcome
Using a disease specific national database, our goal is to

describe maternal characteristics associated with gastroschisis incidence and outcome.

MATERIALS AND METHODS

This study includes all cases of gastroschisis in the Canadian

Pediatric Surgery Network (CAPSNet) database from May

2005 through May 2010
The CAPSNet is a national database representing 16 Canadian

centers, each with a functionally linked high risk obstetrical

center, level III neonatal intensive care unit, and availability of
pediatric subspecialty surgery and anesthesia
Maternal characteristics included: young age (<20 years), illicit

drug use (specifically cocaine), aboriginal ethnicity, smoking

during pregnancy, maternal hometown population, population
density and geographic isolation (hometown 11,000 km from a
tertiary pediatric surgical center or inaccessible by road or
ferry)

 Several neonatal outcome variables were collected. The gastroschisis

prognosis score (GPS) reflects the bowel condition at birth

Features making up the score include the presence and severity of

matting, the presence of atresia, necrosis or perforation.

Other neonatal outcome variables included duration of parenteral

nutrition (PN), and duration of hospitalization

Statistical Analysis :
Analyses were performed using SPSS version 18
Categorical variables were compared using Fishers exact test.

Ordinal data were compared with Mantel-Haenszel test for trend

 Initial univariate and then multivariable analyses were per-

formed with maternal variables chosen a priori (age <20

years, single parent status, alcohol and/or cigarette use
during pregnancy, illicit drug use, cocaine use, geographic
isolation, population density and median income)
Dependent variables included perinatal outcomes

(prenatal care, caesarian section delivery, delivery at

planned center and gestational age of newborn), neonatal
nutritional outcomes (PN duration 130 and 160 days, and
total days of PN) and neonatal clinical outcomes (GPS
moderate or high score, duration of hospitalization, days
of mechanical ventilation and all-cause mortality)
A p value 0.05 was considered statistically significant

RESULTS

Maternal Features Associated with

Gastroschisis
Mothers in this database have a mean age of 22.7 more or less

5.9 years with 110/473 (23%) less than 20 years old

Mothers frequently come from sparsely populated

communities, and 24/501 (4.8%) are geographically isolated

267/535 mothers for whom ethnicity was recorded, white

Caucasian (70%) was most commonly reported followed by

native/aboriginal (18.7%)
161/535 (30%) of mothers reported smoking during pregnancy

(38% of mothers <20 years and 32.3% of mothers >20 years).

This population also reports high illicit drug usage during
pregnancy 115/535 (21.5%)

Pregnancy and Delivery Outcomes

Delivery of prenatal care is excellent for most infants in this

database with 95% receiving some prenatal care and only

3.6% reporting no prenatal care
In univariate analysis, illicit drug use and single parent status

were associated with absence of prenatal care

Multivariable analysis revealed that only single parent status

was independently associated with absence of prenatal care

Geographic isolation was independently associated with

caesarian section delivery

Maternal cocaine use was independently associated with

failure to deliver at the planned institution

Neonatal Outcomes
The overall mortality of all patients included in this

database was 3.2%, with death occurring after a mean

duration of hospitalization of 77 more or less 90 days
Although maternal geographic isolation, cigarette and

cocaine use all had weak association with nutritional outcomes on univariate analysis, none of these features
were independently predictive of worse nutritional
outcomes

 Cocaine use is independently associated with a high GPS

score
While geographic isolation is independently associated

with prolonged hospitalization

No features were independently associated with mortality

or days of ventilation
Maternal aboriginal status forced into the regression

analyses was not an independent predictor of neonatal

nutritional or clinical outcomes

DISCUSSION
In this report, mothers of infants with gastroschisis have a

mean age of 22.7 years, considerably younger than the

average maternal age of 29 reported by Statistics Canada
Young maternal age has been identified as a risk factor

for the development of gastroschisis, Other factors

include smoking, drug use, alcohol consumption,
ibuprofen and vasoactive medication
Caucasian race has an increased association with

gastroschisis when compared with Hispanics and AfricanAmericans

 Aboriginal mothers in this group have a high rate of geographic

isolation (18%), young age (48% are less than 20 years of

age), smoking (47%) and illicit drug use (33%)
There are reports of case clustering and association with poor

socioeconomic status
Cigarette smoking has been linked to an increased incidence of

gastroschisis. The results of our study concur with 31% of the

mothers reporting cigarette smoking during pregnancy
The Canadian Perinatal Health Report identified that 37.2% of

mothers <20 years smoked during pregnancy compared with

an overall maternal smoking rate of 13.4%
The proportion of gastroschisis mothers >20 years old in this

database who reported smoking during pregnancy was 37%,

no different from that of other young mothers

 However, the proportion of mothers >20 years old that

smoked was 34.6%, much higher than expected

This observation suggests that cigarette smoking may

have an even more significant role in the older maternal

population
The proportion of mothers that reported illicit drug use

was 21.5% (marijuana in the majority of cases)

CAPSNet did not collect information on the use of

vasoactive medications or ibuprofen

 It appears that the Canadian female population at risk for

the development of gastroschisis is young, frequently

single and often aboriginal
The prevalence of these risk factors in the population of

mothers with gastroschisis in Canada and the relationship

between these factors and poor perinatal health care
outcomes suggest that targeting at risk groups may
diminish the incidence of gastroschisis and may improve
some of the perinatal health outcomes

 In this larger study, univariate analysis shows a mild

association between cigarette smoking and prolonged

PN, while multivariable analysis no longer shows this
relationship
The relation between cocaine use and bowel injury

remains apparent, with cocaine use independently

predicting severely injured bowel (higher GPS score)
Aboriginals are overrepresented in mothers with gas-

troschisis, yet aboriginal status did not independently

predict adverse outcomes. This provides further evidence
that it is the social and geographic determinants of health
that influence outcome in infants with gastroschisis

 Most infants receive prenatal care in this database. These

results are encouraging when viewed as a reflection of

primary health care provision to mothers in Canada.
There remain, however, mothers who do not receive
adequate prenatal care who tend to be single, from
remote communities and those with substance abuse
issues
There is a tremendous financial and social burden

incurred on the health care system, the community and

families when an infant with gastroschisis is born to a
mother from a remote town

THANK YOU