GOOD MORNING!
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
Chief
Complaint
Pre-natal History
• Mother: 17 y/o, G1P0
• housekeeper
• high school graduate
• denied family history of congenital anomalies and heredofamilial diseases
• cognizant: 3rd month AOG• 1st PNCU- 4th month AOG*• regular intake of Multivitamins
Pre-natal History
• 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 HistoryAPGAR SCORE
0 1 2 SCORE
1min 5min
Heart rate Absent <100 >100 2 2Resp. effort
Absent Weak cry Loud cry 2 2Muscle tone Flaccid Some
flexionActive 2 2
Reflex No response
Grimace Cough / sneeze 1 2
Color Blue, pale
Body pink ext. blue
Pink 1 1TOTAL 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,
• 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
PHYSICALEXAMINATION
• 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
SALIENT FEATURES
ASSESSMENTTerm, 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
• covering is absent• located
paraumbilical,right• 2-4cm• IUGR is common • associated anomalies
less common• herniated organs are
intestines
Omphalocele
• covering is present• located midline
• 2-15cm• IUGR is not common• associated anomalies
more common• herniated organs are
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
• occurs in approximately 1 in 5,000 births
• sporadic
• few familial cases
• occurrence in twins has been reported
GASTROSCHISIS
textbook of surgery- Schwartz
• 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
GASTROSCHISIS
textbook of surgery- Schwartz
• controversy exists regarding the cause of gastroschisis
• defect is caused by abnormal involution of the right umbilical vein*
textbook of surgery- Schwartz
PATHOPHYSIOLOGY
• 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
DIAGNOSIS
• 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
TREATMENT
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
• 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
FLUID MANAGEMENT
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 youThank you