Management of the Infant With Gastroschisis: A Comprehensive Review of the Literature

Mode of Delivery

While the goal of delivery of the newborn with gastroschisis is to optimize their outcome by minimizing trauma to the exposed gastrointestinal contents, the best mode of delivery for these infants remains controversial. From a theoretical standpoint, one might assume delivery by cesarean section would be more advantageous than vaginal delivery for several reasons. The first reason is a cesarean delivery is thought to produce less compromise to the mesenteric circulation because there may be less compression and twisting of the bowel during uterine contractions and passage through the birth canal. Another reason is that the risk of infection to the exposed bowel is decreased by cesarean delivery with intact membranes. The last theoretical disadvantage to vaginal delivery is if a large defect is present with possible liver involvement, there may be an increased risk for avulsion injury.

While the rationale to promote cesarean delivery of the newborn with gastroschisis makes sense from a theoretical standpoint, none of these assumptions have been confirmed by clinical data.^[24] No significant differences in outcomes between cesarean and vaginal delivery were noted in several studies of morbidity associated with gastroschisis and type of delivery.^[22,25,26] The measures of morbidity in these studies included time to full oral feedings, duration of parenteral nutrition, age at discharge, incidence of complications, and number of hospital days.^[22,25] A recent meta-analysis of 15 clinical studies also concluded there is no significant relationship between mode of delivery and infant outcomes.^[27] In addition to the outcomes previously listed, the meta-analysis also found no significant relationship between mode of delivery and rate of primary repair, neonatal sepsis, and pediatric mortality.^[27]

Stabilization and preoperative management of the newborn with gastroschisis must take into consideration many factors, including thermoregulation, fluid volume status, gastric distention and intestinal compromise, infection, respiratory status, and preparation for surgery. Stability of the aforementioned factors is necessary before the impending surgical repair to optimize the infant's outcome.

On delivery, the infant's trunk and lower extremities should be placed in a sterile plastic "bowel bag." The infant should be placed under a preheated radiant warmer and dried to prevent heat loss.^[28] It is also important to ensure that the infant has a patent airway and a naso/orogastric tube in place to prevent gastric distention.^[3] Endotracheal intubation may be indicated if the infant appears to be in distress, although decompression of the gastrointestinal tract may help reduce respiratory compromise.^[4] The infant must be monitored for signs of hypothermia, respiratory distress, and shock. A thorough physical examination should also be performed to determine the presence of other anomalies.^[3,7]

Delivery room management of the infant with gastroschisis has included the use of sterile bowel bags and/or saline-soaked gauze dressings to prevent damage to the exposed intestines.^[29] Sterile, moist gauze dressings, covered by a transparent plastic film have also been used to cover the exposed tissue. The use of moistened gauze dressings is associated with several problems including hypothermia caused by increased insensible water loss and radiant heat loss from the larger surface area of the exposed bowel, tissue trauma, and infection. The bowel bag is the most appropriate alternative.^[28] Bowel bags provide a sterile environment for the exposed intestine and reduce the risk for contamination and tissue trauma. In addition, the bowel bag helps to prevent evaporative heat and fluid losses and enables pooling of fluid within the bag. This pooling of fluid can be measured to provide a more accurate assessment of fluid loss.^[28]

Once initial stabilization in the delivery room is achieved, the newborn is admitted to the neonatal intensive care unit (NICU) for further evaluation and stabilization before surgical repair. Because the newborn with gastroschisis is at an increased risk for fluid loss because of the large surface area of exposed bowel, the newborn may present with symptoms of shock.^[30] Fluid resuscitation with isotonic solutions such as normal saline or Ringer's lactate is recommended for the newborn in shock.^[31,32] Fluid resuscitation is usually continued until the infant's urine output normalizes and/or blood gases indicate normal acid-base balance.^[31] The maintenance fluid requirement for infants with gastroschisis is increased 2- to 3-fold because of the excessive losses through the exposed bowel.^[31,32] When fluid orders are written, it is important to keep in mind the glucose load associated with the intravenous fluids. Placing the newborn with a gastroschisis on a dextrose solution at two to three times the usual maintenance rate increases the likelihood of hyperglycemia.

The newborn with gastroschisis is at constant risk for hypothermia because of the large surface area of exposed bowel. The use of warm, saline-soaked gauze to cover the defect may increase the risk of hypothermia as the saline cools.^[28] Care must be taken to prevent cold stress by keeping the infant on a radiant warmer or other external heat device, and by minimizing fluid and heat loss from the exposed bowel.^[19]

The infant must be continually assessed for signs of gastrointestinal compression before surgical repair. A naso/orogastric tube should be inserted and placed to intermittent suction to keep the bowel and stomach decompressed.^[29,33] Decompression is important because it helps to prevent partial or total obstruction of blood flow and oxygenation to the bowel. If decompression does not occur, there is an increased risk for bowel necrosis secondary to the constriction of the exteriorized intestine through the small visceral defect. Decompression will also reduce the infant's risk for emesis and thus aspiration.^[33]

Bowel compromise can occur during positioning of the infant. Infants with gastroschisis should be positioned on their right side in a lateral decubitus position to enhance venous blood return from the gut.^[29] The right lateral decubitus position also decreases the risk of decreased perfusion caused by compression or kinking of mesenteric vessels.^[20] It is important to make frequent assessments of perfusion to the intestines with minimal handling of the exposed tissue.

Diagnostic testing and antibiotic prophylaxis are the last two areas of presurgical management. While the specific tests may vary from NICU to NICU, the most common presurgical studies ordered include a baseline chest x-ray, complete blood count (CBC) with differential and platelets, arterial blood gas, serum electrolytes, blood glucose level, total protein, and a blood type and cross match.^[3] Broad-spectrum antibiotics such as ampicillin and gentamicin are started to decrease the risk of infection from bacterial contamination of the exposed bowel.^[33,34]

NAINR. 2003;3(2) © 2003 W.B. Saunders

Cite this: Management of the Infant With Gastroschisis: A Comprehensive Review of the Literature - Medscape - Jun 01, 2003.