Introduction
Birth defects are quite common in children whose mothers have been using and abusing certain drugs more so, illegal ones. One of the most common birth defects in children is known as gastroschisis. Gastroschisis belongs to a category of birth defects called ventral wall defects. These defects involve the belly (abdominal) area of the baby/ fetus. It results in the free extension of the fetal bowels in amniotic fluid space via a minute opening in the fetus’ abdomen. This is mostly in the right side of the belly button (umbilicus). More often than not, gastroschisis involves part of the large intestine and the small intestine spilling in the amniotic fluid surrounding the fetus.
Gastroschisis is prevalent in about 1 in every 500 live births and more often than not occurs in babies born to mothers below the age of 20. It is important to acknowledge that there is no particular cause associated with gastroschisis. However, studies show that mothers who have been using vitamins in the course of their pregnancy stand higher risks of giving birth to children with birth defects of which gastroschisis is one. Unlike other defects of the abdominal wall, gastroschisis is basically not related to structural anomalies such as chromosomal anomalies except intestinal atresia or blockage. This occurs in approximately 10% of the cases.
Diagnosis
Gastroschisis is mainly diagnosed by ultrasound and in most cases following an imminent maternal serum alpha-fetoprotein tests done in the pregnancy’s second trimester. Gastroschisis prenatal diagnosis allows the parents to plan and discuss the options pertaining to postnatal management with the pediatric surgeon and obstetrician. Families with diagnosed gastroschisis undergo comprehensive level 2 ultrasound evaluation. It is always important that the individuals undergo other tests to distinguish gastroschisis with other abdominal wall defects like omphalocele. Once the initial consultations and evaluations have been conducted, the physician and the family would formulate a personalized management as well as follow-up plan to aid in the recovery of the child.
Having in mind that gastroschisis involves the exposure of fetal intestines to amniotic fluid in which case they are unprotected in the course of the pregnancy, complications such as lower fetal growth, lower volume of the amniotic fluid, bowel dilation and preterm delivery have a high likelihood of occurrence more so in the third trimester. This underlines the importance of close surveillance of the condition in the third trimester by the use of sonography combined with fetal surveillance monitoring (volume of amniotic fluid, Doppler ultrasound, biophysical profile) to monitor the fetal well-being and determine the right time for delivery.
Gastroschisis repair
Gastrointestinal repair involves surgical correction where the extra abdominal bowel is returned back to the abdominal cavity. This is then followed by the closure of the abdominal wall. It is important to acknowledge that this is done immediately after the birth of the child. In most cases, these children are born through the cesarean section.
Gastroschisis repair may be performed either with immediate primary repair of the condition or more often than not staged repair approach. This depends on the postnatal assessment of exposed bowel condition.
Primary gastroschisis repair
This involves reducing the extra bowel and closing the abdominal wall in a single operation. However, many are the times when the primary gastroschisis repair is not feasible due to the risk of bowel inflammation and dilation resulting from exposure of fetal intestines to amniotic fluid.
Staged gastroschisis repair approach
This approach kicks off once the child has been delivered. In this case, the abdominal contents that are exposed would be placed in protective covering before the infant is transferred to the infant or newborn center. Once admitted to the center, a silastic sheeting more commonly known as SILO would be placed around the exposed or herniated bowels. This silo would then be reduced every day at the bedside up to such a time when the abdominal contents get level with the abdominal skin. Once the abdominal contents are level with the abdomen the final closure of the abdominal wall is done. During the final closure, ventilator or breathing assistance would be necessary. The surgeons wait until the baby has become stable enough to undergo surgery. The waiting period may take between a week and ten days. Once the baby is ready to undergo surgery, he or she will be placed under general anesthesia in which case they will be asleep and experience no pain in the course of the operation.
The surgeon examines the bowels carefully for birth defects or indications of damage. Any unhealthy parts are removed while healthy edges are stitched together. All the abdominal organs lying outside the belly would be placed into the abdomen before the opening is repaired. In some cases, more surgery will be required later in order to repair the belly’s muscles.
Post surgery procedures
As much as the abdominal closure is done with gastroschisis repair, quite some time passes before the intestines recover fully from the condition. In this case, the first feeding is provided intravenously. With return of the bowel function evidenced by passing of bowel movement, the feeding through nasogastric (NG) tube is slowly initiated while the IV feeds continue. Breast milk may be pumped and frozen for the NG feeds in case it is tolerated. If not, special alimental formula may be given. The NG feeding is gradually increased while oral feeding is also introduced.
Potential complications
Quite a number of complications are likely to occur caused by the varied procedures on e undergoes including-:
Anesthesia- allergic reactions to drugs, breathing difficulties
Surgery- infections, bleeding and blood clots
Other likely complications of gastroschisis include-:
Breathing problems in case the abdominal space of the baby is small. This necessitates the use of breathing machine or breathing tube for some time after surgery
Organ injury
Inflammation of tissues lining the abdominal wall and covering the abdominal organs
Problems with absorption of nutrients from the food and even digestion more so if the small bowels had been extensively destroyed.
Success rates
Enhanced surgical techniques as well as neonatal care have ensured a high success rate. 85-90 % of the babies born with gastroschisis have survived. This however does not undermine the fact that long hospitalization is required not to mention the occurrence of complications more so pertaining to intestinal functioning. Since the condition is treated at infancy, if short-bowel syndrome complications do not occur, treatment is quite successful (above 85% success rates).
Why use High Frequency Jet Vent rather than High Frequency Oscillator Vent
High frequency jet vent HFJV is preferred to the High Frequency Oscillator Vent HFOV due to the high frequency pulmonary gas exchange and ventilation. This means that the carbon dioxide produced by the infant would be more efficiently excreted in a given minute.
Conclusion
While gastroschisis is quite a serious condition which could actually lead to infant mortality, iit is important to acknowledge that surgical method has prove to be quite effective in remedying the condition with very high success rates. This is complemented by the technological advancement as well as more knowledge in neonatal procedures.
References
Parker SE, Mai CT, Canfield MA, Rickard R, Wang Y, Meyer RE, et al; for the National Birth Defects Prevention Network. Updated national birth prevalence estimates for selected birth defects in the United States, 2004-2006. Birth Defects Res A Clin Mol Teratol. 2010 Sept 28. [Epub ahead of print]
Bird TM, Robbins JM, Druschel C, Cleves MA, Yang S, Hobbs CA, & the National Birth Defects Prevention Study (2009). Demographic and environmental risk factors for gastroschisis and omphalocele in the National Birth Defects Prevention Study. J Pediatr Surg, 44:1546-1551.
Williams LJ, Kucik JE, Alverson CJ, Olney RS, Correa A. Epidemiology of gastroschisis in metropolitan Atlanta, 1968 through 2000. Birth Defects Res A. 2005; 73:177-83.
Feldkamp ML, Reefhuis J, Kucik J, Krikov S, Wilson A, Moore CA, Carey JC, Botto LD and the National Birth Defects Prevention Study. Case-control study of self reported genitourinary infections and risk of gastroschisis: findings from the national birth defects prevention study, 1997-2003. BMJ. 2008 Jun 21; 336(7658): 1420-3.
