Gastroschisis

Neonatal Disease

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 Gastroschisis

Overview: 

Gastroschisis is a congenital abdominal wall defect in which an opening occurs, typically to the right of the umbilical cord. Unlike omphalocele, another abdominal wall defect, gastroschisis involves herniation of abdominal organs outside the fetal abdomen without a protective covering. 

1. Causes: 

  • Gastroschisis is a type of hernia. Hernia means rupture. Babies with this condition have a hole in the abdominal wall. The child's intestines usually stick out (protrude) through the hole. 

  • The condition looks similar to an omphalocele. An omphalocele, however, is a birth defect in which the infant's intestine or other abdominal organs protrude through a hole in the belly button area and are covered with a membrane. 

  • Other related birth defects are rare in patients with gastroschisis. 

 

2. Pathophysiology:

During fetal development, a failure in the closure of the abdominal wall allows intestines and

sometimes other organs to protrude into the amniotic fluid. Unlike omphalocele, there is no sac

covering the herniated organs in gastroschisis. 

3. Clinical Presentation:

  • Visible Herniation: Organs, usually the intestines, are visible outside the abdomen. 

  • No Protective Sac: Unlike omphalocele, there is no sac covering the exposed organs. 

  • Prematurity: Gastroschisis is often associated with premature birth. 

  • Compromised Blood Supply: The herniated organs may be edematous and may have

    compromised blood supply. 

 

4. Diagnostic Evaluation: 

  • Ultrasound: Prenatal ultrasound is crucial for diagnosing gastroschisis. It can visualize the herniation and aid in planning for postnatal care. 

  • Postnatal Assessment: Clinical examination after birth confirms the diagnosis, and additional imaging may be done to evaluate the extent of organ involvement. 

 

5. Management: 

  • Delivery Planning: Early detection allows for planned delivery at a facility with expertise in neonatal surgery and care. 

  • Immediate Surgery: Surgical intervention is typically required shortly after birth. The exposed organs are gradually returned to the abdominal cavity, and the abdominal wall is closed. 

  • Intensive Care: Infants with gastroschisis often need intensive care, including respiratory support and nutritional management. 

  • Monitoring for Complications: Close monitoring is essential for potential complications, such as infection or intestinal dysfunction. 

 

6. Prognosis:

With timely intervention and appropriate medical care, many infants with gastroschisis can have a positive outcome. The prognosis is influenced by factors such as the degree of bowel involvement, associated complications, and the presence of other congenital anomalies. 

Long-Term Considerations: While many infants with gastroschisis can lead healthy lives after corrective surgery, there may be long-term considerations such as the potential for intestinal dysfunction or the development of scar tissue. 

Supportive Care: A multidisciplinary approach involving neonatologists, pediatric surgeons, nurses, and other specialists is crucial for providing comprehensive care to infants with gastroschisis. 

Gastroschisis requires prompt recognition, early intervention, and ongoing medical management to optimize outcomes for affected infants. 

 

7. Laboratory Studies: 

  • Physical examination of the infant is enough for the health care provider to diagnose gastroschisis. The baby will have problems with movement and absorption in the gut, because the unprotected intestine is exposed to irritating amniotic fluid. 

  • The mother may have shown signs of too much amniotic fluid (polyhydramnios). A prenatal ultrasound often identifies the gastroschisis                              

 

8. Treatment:  

The primary treatment for gastroschisis involves surgical intervention. Here are the key steps in the treatment process: 

  • Prenatal Diagnosis and Planning: 

  • Ultrasound: Prenatal diagnosis is often made through ultrasound, which allows visualization of the abdominal wall defect. 

  • Delivery Planning: Early detection allows for planning the delivery at a facility equipped with a neonatal intensive care unit (NICU) and experienced in the management of neonates with gastroschisis. 

  • Immediate Postnatal Management: 

  • Prompt Surgery: Surgical intervention is typically required shortly after birth. The exposed abdominal organs, commonly the intestines, are gradually and carefully placed back into the abdominal cavity. 

  • Closure of Abdominal Wall: The surgeon works to close the opening in the abdominal wall. In some cases, if the defect is too large, a staged closure may be necessary. 

  • Postoperative Care in the NICU: 

  • Respiratory Support: Infants with gastroschisis may need respiratory support, and mechanical ventilation may be required initially. 

  • Nutritional Support: Nutritional management is crucial, and parenteral nutrition or enteral feeds may be initiated to support the infant's growth and development. 

  • Monitoring and Management of Complications: 

  • Infection Control: Due to the exposed nature of the abdominal organs, there is a risk of infection. Strict infection control measures are implemented. 

  • Complications: Close monitoring for complications, such as bowel obstruction, infection, or vascular compromise, is essential. 

9. Complications: 

The misplaced abdominal contents can make it difficult for the baby to expand the lungs, leading to breathing problems. Another complication is bowel death. This occurs when intestinal tissue dies due to low blood flow or infection. 

What does the NICU RT need to be ready for when dealing with gastroschisis?

When caring for a neonate with gastroschisis, a NICU respiratory therapist (RT) must be prepared for several critical challenges. These infants often require respiratory support due to potential prematurity and the development of respiratory distress syndrome (RDS), necessitating close monitoring of respiratory rates and oxygen saturation. Hypothermia is a significant concern, as the exposure of abdominal organs increases heat loss, requiring the RT to support thermal regulation using radiant warmers. Fluid and electrolyte imbalances are common due to fluid loss from the exposed intestines, and RTs should monitor blood gases and collaborate with the care team for proper hydration. Post-surgery, the RT must be vigilant for respiratory complications like aspiration or abdominal compartment syndrome, which can affect lung compliance. Additionally, because these infants are at increased risk for infections, including sepsis, RTs must remain prepared to manage respiratory failure or septic shock if complications arise. Ensuring adequate ventilation, maintaining oxygenation, and monitoring for signs of infection are critical in supporting these infants’ overall care​.