Gastroschisis

Congenital full-thickness abdominal wall defect (usually just right of the umbilicus) that allows intestines (and sometimes other organs) to herniate outside the body without any protective membrane.

• Although rare (~1 in 2,500 births), gastroschisis has increased in incidence in recent decades, especially in babies born to young mothers. It is the most common neonatal abdominal wall defect and a surgical emergency requiring prompt neonatal care. Survival exceeds 90% with proper treatment, but complications (intestinal atresia, short gut, infection) can cause significant morbidity. Differentiating gastroschisis from omphalocele (which has a membranous sac and often other anomalies) is a classic exam topic.

• Prenatal: elevated AFP on screening and second-trimester ultrasound showing free-floating bowel loops in amniotic fluid (no enclosing sac).
• Newborn: intestines protruding through a right-sided abdominal wall hole next to an intact umbilical cord, with no covering membrane. The exposed bowel often appears edematous and matted (from amniotic fluid exposure).
• Typically an isolated defect (normal karyotype, no major extra-GI anomalies), unlike omphalocele. Babies are often born premature or small for gestational age (intrauterine growth restriction). Risk factors include maternal age <20, smoking, or other substance use.

1. Differentiate gastroschisis vs omphalocele: gastroschisis is usually right of midline with no sac; omphalocele is midline at the cord base with a peritoneal sac covering the herniated contents (and often involves liver and other organs).
2. Prenatal management: serial ultrasounds to monitor bowel condition; plan delivery at a tertiary center with pediatric surgery and neonatal ICU. Vaginal delivery at ~37–38 weeks is often acceptable if no other contraindications (no need for C-section purely for gastroschisis).
3. Immediately after birth, focus on protecting the bowel and stabilizing the infant: cover exposed intestines with sterile saline dressings or a plastic bowel bag to prevent heat/fluid loss, place an NG/OG tube to decompress the stomach, start IV fluids, and broad-spectrum antibiotics.
4. Evaluate the bowel for signs of compromise (atresia, ischemia). Classify as simple (gastroschisis without intestinal complications) or complex (if intestinal atresia, perforation, or necrosis is present) to anticipate surgical needs.

1. At delivery, immediately protect the bowel and stabilize the newborn: wrap the exposed intestines in a sterile plastic covering (bowel bag) to prevent drying/heat loss, place the baby supine without kinking the mesentery, and begin fluid resuscitation and gastric decompression (NG tube).
2. Urgent surgical closure of the defect is required. If feasible, perform a primary closure shortly after birth (closing the abdominal wall in one operation). If the bowel volume is too large or abdominal cavity is small, use a silo (silastic pouch) for staged reduction of the intestines over several days followed by final closure.
3. Provide intensive neonatal care: ventilatory support as needed (especially if closure increases intra-abdominal pressure), TPN for nutrition until bowel function returns, and antibiotics. Gradually introduce enteral feeds once the gut recovers. Manage any short bowel syndrome if significant lengths of intestine were removed.

• Omphalocele has a seal (membrane) around the organs, whereas gastroschisis has no covering (guts "free").
• Gastroschisis tends to be Right-sided (to the Right of the cord), while omphalocele is On the midline (through the umbilical Opening).

• Discolored or dusky bowel on exam (suggesting compromised blood flow) → urgent surgical evaluation for resection to prevent necrosis and sepsis.
• Signs of abdominal compartment syndrome after closure (tense abdomen, impaired ventilation, low urine output) → may require opening the closure or silo to relieve pressure.
• Neonatal sepsis (fever, lethargy, hypotension) in gastroschisis can develop rapidly from gut translocation or necrosis—start broad antibiotics and evaluate immediately.

1. Prenatal diagnosis (high AFP, ultrasound) of gastroschisis → plan delivery at a center with pediatric surgery and NICU available.
2. At birth: maintain airway, keep baby warm, and immediately cover exposed bowel with sterile plastic; begin fluid resuscitation, place NG tube, and give antibiotics.
3. Surgical management: attempt primary closure of the abdominal wall defect if possible; if not, place a silo for gradual bowel reduction over ensuing days, then surgical closure.
4. Post-op: monitor in NICU for complications (compartment syndrome, infection, feeding intolerance). Provide TPN and supportive care until bowel motility returns, then initiate feedings and wean off IV nutrition.

• Teenage primigravida with elevated AFP on prenatal screening and ultrasound showing free-floating intestinal loops → likely gastroschisis.
• Newborn with loops of bowel protruding beside the umbilicus and no membranous sac covering them → gastroschisis (vs a sac-covered midline omphalocele).