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 General Objective
To present a case of an anterior
abdominal wall defect
 Specific Objectives
To discuss the presentation, causes and prognosis of
gastroschisis

To discuss the medical and surgical management of

gastroschisis

To compare the two most common anterior

abdominal wall defects: omphalocoele and
gastroschisis
 General Data
• Baby Boy V
• newborn
• Trancoville, Baguio City
• born and admitted:
February 17,2010 at 1:53pm
 i f
e nt
h
C pla i
om
C
 Pre-natal History
• Mother: 17 y/o, G1P0
• housekeeper
• high school graduate
• denied family history of congenital
anomalies and heredofamilial diseases
 Pre-natal History
• cognizant: 3rd month AOG
• 1st PNCU- 4th month AOG*
• regular intake of Multivitamins
• URTI : 5month AOG
• (-) exposure
viral exanthematous diseases, radiation,
alcohol beverages and cigarette
 Pre-natal History
• LMP- May 29,2009
• EDC by LMP – March 5, 2010
• AOG by LMP- 38-39wks
12 days prior to delivery……
Single, live intrauterine fetus in cephalic
presentation, 32weeks and 3 days AOG.

Extra-abdominal tubular structures

probably bowel loops due to an
anterior wall defect (gastroschisis)
Perinatal History
13 hours prior to delivery
↓
labor pains

↓
8 hours prior to delivery
↓
BGHMC-ER
• single, live intrauterine pregnancy in cephalic
presentation, 33weeks AOG by fetal biometry
• posterior placenta Grade II-III maturity,
modified BPPS of 8/8, normohydramnios
• consider fetal abdominal defect probably
gastroschisis

• expected date of delivery: 3/31/10

• expected fetal weight: 2285g
 Natal History
APGAR SCORE
SCORE
0 1 2
1min 5min

Heart rate Absent <100 >100

2 2
Resp. effort Absent Weak cry Loud cry
2 2
Muscle tone Flaccid Some flexion Active
2 2
Reflex No
response
Grimace Cough /
sneeze 1 2
Color Blue,
pale
Body pink
ext. blue
Pink
1 1
TOTAL SCORE
8 9
BALLARD SCORING

19
Ballard Scoring

19
 PHYSICAL EXAMINATION

• General Survey: active,

hypothermic with good and loud
cry, in mild respiratory distress
• Vital Signs
– respiratory rate: 48/min
– cardiac rate: 147/min
– temperature: 36.1ºC
 ANTHROPOMETRIC MEASUREMENTS

• Birthweight:1.9 kg (below 10th percentile)

• Birth length: 42 cm (below 10th percentile)
• Head circumference: 31cm
(below 10th percentile)
• Chest circumference: 27cm
• Abdominal circumference: 26cm
• Arm:10cm
 PHYSICAL EXAMINATION
• Skin: pink body, blue extremities,
with cracking, pale areas, rare veins
and bald areas of lanugo
• HEENT: normocephalic, non-bulging
anterior and posterior fontanelles, no
facial asymmetry, anicteric sclerae,
ears are formed and firm with instant
recoil, (+) alar flaring, no cleft lip, no
cleft palate
 PHYSICAL EXAMINATION
• Chest and lungs: symmetrical chest
wall expansion, (+) grunting
respiration, no tachypnea, no
retractions, good and equal air entry

• Heart: adynamic precordium, normal

rate, regular rhythm, PMI at 4th ICS,
LMCL,no murmurs
 Abdomen

Scaphoid,
(+) evisceration of
edematous intestines,
no sac, noted at the
paraumbilical area,
right, abdominal wall
defect measures 2.5
cms by 2.5 cms, with
intact umbilicus,
 PHYSICAL
EXAMINATION
• Ano-genital:grossly male, testes
down, good rugae, patent anus

• Extremities: no gross deformities, pink

nail beds, creases over all over, equal
and full peripheral pulse, good
capillary refill
 SALIENT FEATURES
• term, newborn, male
• scaphoid abdomen,
• (+) evisceration of edematous
intestines, no sac, noted at the
paraumbilical area, right,
abdominal defect measures 2.5 by
2.5 cms, with intact umbilicus
 ASSESSMENT
Term, male, 38-39 weeks Age of
Gestation by Ballard Scoring, born
via “E” Low Segment Cesarian
Section, for Fetal Abdominal
defect, and Non-reassuring Fetal
Status with a Birthweight of 1.9
kg, Low Birth Weight, Small for
gestational Age, Abdominal wall
defect, Gastroschisis
GASTROSCHISIS
OMPHALOCELE

O
 Gastroschisis Omphalocele
• covering is absent • covering is present
• located • located midline
paraumbilical,right
• 2-4cm • 2-15cm
• IUGR is common • IUGR is not common
• associated anomalies • associated anomalies
less common more common
• herniated organs are • herniated organs are
intestines intestine, stomach,
liver, spleen

nelson's 16th edition

 On admission…..
Patient immediately brought in the Nursery
Diagnostics:
– CBC, Platelet Count, Typing, Blood
C&S,
Hgb- 151
Hct- 0.49
WBC- 33.9 (neu-.22,lymp-.71,mid cells-
.07)
Plt.ct-535
– Hemogluco test: 80 mg/dl
– CXR
Therapeutics:

– Routine Newborn care was done

– D10W with TFR-60cc/kg as maintenance
line, and PNSS at 10 cc/kg/hour until OR
– FFP*
– Ampicillin IV at 50mg/kg/dose
– Amikacin IV at 15mg kg/dose
– Metronidazole at 15mg/kg as loading dose,
7.5mg/kg as maintenance dose
– immediately referred to
Pediatric surgery
– scheduled for “E” primary
abdominal wall repair
postoperatively……..

patient was immediately

brought Neonatal Intensive
Care Unit for post-op care
 GASTROSCHISIS
• occurs in approximately 1 in 5,000
births
• sporadic
• few familial cases
• occurrence in twins has been
reported

textbook of surgery- Schwartz

 GASTROSCHISIS
• herniation of abdominal contents
through a paramedian full-
thickness abdominal fusion defect
• the abdominal herniation is
usually to the right of the
umbilical cord
• no genetic association exists
 GASTROSCHISIS
• usually contains small bowel and has
no surrounding membrane

• the herniated bowel is non-rotated

and devoid of secondary fixation to
the posterior abdominal wall
 GASTROSCHISIS
• intestine maybe normal in
appearance
• thick, edematous, discolored and
covered with exudates, implying a
more long standing process

textbook of surgery- Schwartz

 PATHOPHYSIOLOGY
• controversy exists regarding the cause
of gastroschisis

• defect is caused by abnormal involution

of the right umbilical vein*

textbook of surgery- Schwartz

 DIAGNOSIS
• antenatal detection rates are 70-72%
• prenatal sonography: primary imaging
modality
• fetal AFP level: 200-300 times as high
as the concentration in amniotic fluid
 TREATMENT
• Primary gastroschisis repair
– the baby undergoes surgical
repair immediately after birth
– this is the preferred method of
repair because it is associated
with a reduced risk of infection
and fluid loss

textbook of surgery- Schwartz

• Staged gastroschisis repair

– the bowel is covered by a sheet of

protective material and allows
graduated reduction on a daily basis
as the edema in the bowel decreases.

textbook of surgery- Schwartz

• A Silastic (silicone plastic) pouch is
first placed over the baby's exposed
bowel and anchored to the
surrounding muscle. Each day, the
pouch is tightened to push the
intestine back into the abdominal
cavity.

textbook of surgery-schwartz
 FLUID MANAGEMENT
• maintenance fluids + deficit
computed at 10-20cc/kg per number
of hours herniated organs exposed
• run PNSS in between transfusion of
FFP and albumin
• run maintenance fluid on a separate
line

nelson's 16th edition

 MORTALITY AND MORBIDITY
• postoperative hospital stay is often lengthy
• complications occur frequently, especially
related to the gastrointestinal tract.
• survival rates after surgery are 87-100%.
• mortality rate of 17%
textbook of surgery- Schwartz
 MORTALITY AND MORBIDITY
• most deaths occur as a result of premature
delivery, sepsis, and bowel infarction
• poor prognosis:
– evidence of bowel damage, such as atresia
– necrosis, or severe dilatation or
thickening of the bowel, or the inability to
close the abdominal defect

textbook of surgery- schwartz

Thank you