ONFALOCELE Y GASTROSQUISIS PDF

Prenatal diagnosis and management of the fetus with abdominal wall defect. Semin Perinatol ; Kamata S, lshikawa S, Usui N. Prenatal diagnosis of abdominal wall defects and their prognosis.

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Received: May 29; Accepted: February Gastroschisis is a low-prevalence disease with a very good prognosis, if initial management is adequate. This paper attempts to describe the disease and highlight the importance of correct treatment at the primary care level. Newborn child diagnosed with gastroschisis in a primary care center, referred to the Neonatology Service of a tertiary care institution. He received interdisciplinary management and underwent gradual surgical closure, with favorable outcome after a three-month hospitalization.

There is no clarity about the exact cause of gastroschisis, since it is a multifactorial disease. It can be diagnosed during the prenatal stage by means of ultrasonography, which has high sensitivity and specificity for its detection. Gastroschisis is a disease that requires adequate knowledge from both specialized and primary care personnel, as it ensures a correct initial management and avoids future complications. No existe claridad sobre la causa exacta de la gastrosquisis, ya que es una enfermedad multifactorial.

Gastroschisis can be defined as a congenital defect of the anterior abdominal wall, characterized by evisceration of the abdominal organs through an opening in the absence of membranous coverage; this defect is usually observed to the right of the navel 1 - 3 , involving, in all cases, the small intestine 3 and sometimes the stomach, colon or gonads. This paper reports the case of a full-term male infant born at 37 weeks, who was transferred from Florencia, Colombia to the Neonatology Service.

The child was born by vaginal delivery at a primary care center, with an incidental finding of protruding, violaceous and wet intestinal loops, associated with respiratory distress. The patient received oxygen therapy through cannula and nasogastric tube.

Ophthalmic prophylaxis was performed and then, he was referred to a secondary care institution, where gastric lavage was performed, a polyethylene bag was placed, and antibiotic treatment with ampicillin-gentamicin was initiated.

The child was referred to a tertiary care institution for management by Pediatric Surgery. Obstetric ultrasounds at weeks 19 and 29 of pregnancy did not report alterations and fetal movements were positive since month two. The child was fully vaccinated. No pathological, infectious, pharmacological or transfusion history were observed other than maternal poisoning during the first trimester of pregnancy with insecticide, since the mother lives in an area where constant fumigations are performed.

On physical examination, the patient presented with stable vital signs and normal anthropometric measurements abdominal perimeter was not assessed due to the protrusion of intestinal loops. The thorax showed a slight intercostal retraction and the abdomen, a protrusion of intestinal loops covered with a viaflex container, pink, well perfused and with a foul odor; the skin was pale and poorly perfused.

Table 1. Synthesis of the evolution of the patient. Source: Own elaboration based on the data obtained in the study. Based on clinical findings, gastroschisis, respiratory distress syndrome and early neonatal sepsis were diagnosed. Renal ultrasound and echocardiogram were requested to rule out associated congenital malformations; the results were normal. Clinical genetics determined a chemical teratogenic disruptive process during the first trimester of pregnancy as probable etiology.

Taking into account his history, a k-band karyotype was requested, which was not authorized by the health service provider, so it was not possible to use it as a diagnostic tool to establish management. This case report does not address the importance of the denied examination. The patient required mechanical ventilation and inotropic support. The Pediatric Surgery Service proposed closing the abdominal wall gradually and adding metronidazole to antibiotic management. During surgery, severe gastro schisis was found with exposure of stomach, small and large intestines, intestinal malrotation with thickened meso, and leaky and thickened intestine due to intrauterine exposure.

The procedure was well tolerated at first, but a deterioration of the clinical condition was observed subsequently with hemodynamic instability, which required inotropic support with dopamine and dobutamine; mechanical ventilation with high parameters; sedation with fentanyl and morphine; relaxation with rocuronium, and follow-up with antibiotic therapy with ampicillingentamicin and metronidazole.

The Pediatric Surgery Service decided to perform plications of the viaflex container. The first was done 3 days after the first surgery and the second and third were performed at intervals of 24 hours after the first plication. A second surgery was planned hours after the last plication. However, chest x-ray findings were interpreted as possible acute disseminated candidiasis, so the procedure was postponed. Pediatric Pneumology ruled out said infection, so the second surgery was performed 4 days after the last plication Figure 1.

During the procedure, gastroschisis was corrected with myocutaneous and fasciocutaneous flap. After removing the viaflex container, a thickened, dysmorphic and malrotated intestine was observed.

Figure 1. Secong surgery. If gastroschisis is a small defect only a part of the intestines protrudes from the abdomen , it is usually treated with surgery soon after birth Figure 1.

However, if gastroschisis is a large defect many organs protrude from the abdomen , repair could be done slowly, in stages, covering the exposed organs with a special material and placing them slowly in the abdomen. After the organs have been arranged inside the abdomen, the opening is closed. In the postoperative period, the patient remained hemodynamically stable, achieving inotropic and vasoactive weaning.

Pharmacological relaxation and morphine were discontinued and fentanyl was administered only at analgesic doses. Mechanical ventilation was continued in a controlled assisted manner with minimal parameters and intra-abdominal pressure between mmHg. The patient remained hospitalized for days; his evolution was satisfactory and the food was well tolerated with normal stools and adequate weight gain reaching 3 grams.

The patient was discharged with breastfeeding on demand, supplemented extensively with hydrolyzed milk formula. The first gastroschisis report was published in Table 2. Differences between gastroschisis and omphalocele. Source: Own elaboration based on 1 , 3 , 5 , 6. A review of the period in the Clinical Hospital of the University of Chile showed that the figure was 2.

It should be noted that the mother of the studied patient was 17 years old, primigravida, exposed to a toxic substance insecticide in the first trimester of pregnancy and of low socioeconomic status. There is no certainty about the exact cause of gastroschisis, since it is a multifactorial disease. Embryologically, the abdominal wall originates from the lateral mesoderm and by the fusion of four folds cephalic, caudal and two lateral foldings , which grow towards the midline, con verging in the umbilical ring that is completed around the fourth week.

A new theory proposes that there is a defect in the inclusion of the yolk sac in the fetal body stem, with the consequent formation of an additional opening through which the intestine is eventracted, instead of doing it through the umbilical cord. A gastroschisis diagnosis can be achieved in the prenatal stage by means of an ultrasonography, which has high sensitivity and specificity for its detection.

Prenatal detection of this disease is important because it allows timely genetic counseling, since performing a karyotype is not recommended in these patients given the limited association of this defect with other genetic syndromes. There are useful ultrasound predictors to estimate the possibility of neonatal complications, such as intestinal atresia.

Once the prenatal diagnosis is made, a multidisciplinary approach obstetrician, neonatologist, pediatric surgeon and bi-monthly sonographic controls are required to monitor markers to predict complications. Several studies suggest that early caesarean section weeks decreases morbidity with respect to vaginal delivery due to the supposed risk of infection or perforation of the viscera exposed during the latter, while other authors do not find significant differences.

The scheme presented below should be followed after the birth of a child without a prenatal diagnosis, which is similar to what was presented in this clinical case. There are two types of closures: primary and gradual. Some of the factors associated with the success of primary closure include patients classified as low risk and born intrainstitutionally and in reference centers. Several studies have found that this technique has an effectiveness profile similar to conventional closure, and that, in fact, in low-risk patients, it is associated with a lower requirement of mechanical ventilation and a decrease in the incidence of surgical wound infections.

In addition, the closing without sutures technique, using flaps with autologous tissue, can be performed outside the operating room, decreasing anesthesia requirements and costs for health institutions.

According to bioethical parameters, the efforts during any procedure should be directed to achieve the optimal resolution of the beneficence, nonmaleficence, autonomy, justice and equity principles, which guarantee adequate interdisciplinary management. When analyzing the conflict of principles, the lack of a timely prenatal diagnosis was evident 20 , thus preventing adequate follow-up at an appropriate level of complexity and the choice of early cesarean section, which has shown effects on mortality.

Regarding the management of this case, it is worth highlighting the optimal initial treatment, timely referral from the primary care institution, adequate information to relatives and the successful interhospital communication, which demonstrate full support to the beneficence and autonomy principles. This research was authorized by the legal guardian of the minor and respected the confidentiality of the patient and his relatives.

Gastroschisis is a congenital defect that, despite its low frequency, requires adequate knowledge not only from specialized personnel, but also from primary care physicians, taking into account that they are obliged to ensure an appropriate and timely referral of the patient to a higher complexity level to avoid complications.

Clinical risk factors for gastroschisis and omphalocele in humans: a review of the literature. Pediatr Surg Int. Differential diagnosis of abdominal wall defects - omphalocele versus gastroschisis. Teratogens inducing congenital abdominal Wall deffects in animal models. Svetliza J. Poddar R, Hartley L. Exomphalos and gastroschisis. Defectos de cierre de la pared abdominal: Gastrosquisis. Prog Obstet Ginecol. Tassin M, Benachi A.

Diagnosis of abdominal wall defects in the first trimester. Curr Opin Obstet Gynecol. Gastroschisis: Antenatal sonographic predictors of adverse neonatal outcome. Journal of Pregnancy. Cir Pediatr. Agricultural-related chemical exposures, season of conception, and risk of gastroschisis in Washington State. Am J Obstet Gynecol. Maternal residential atrazine exposure and gastroschisis by maternal age. Matern Child Health J. When clossure fails: What the radiologist needs to know about the embryology, anatomy, and prenatal imaging of ventral body wall defects.

Gastroschisis: Preterm or term delivery?. Colomb Med. Non-genetic risk factors for gastroschisis. Bol Med Hosp. Gastroschisis: etiology and developmental pathogenesis. Clin Genet.

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Received: May 29; Accepted: February Gastroschisis is a low-prevalence disease with a very good prognosis, if initial management is adequate. This paper attempts to describe the disease and highlight the importance of correct treatment at the primary care level. Newborn child diagnosed with gastroschisis in a primary care center, referred to the Neonatology Service of a tertiary care institution. He received interdisciplinary management and underwent gradual surgical closure, with favorable outcome after a three-month hospitalization.

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Onfalocele y gastrosquisis. Más que una diferencia clínica

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