Gastroschisis

Key Points

• Gastroschisis is an abdominal wall defect to the right of the umbilicus where intestines herniate without a protective sac.
• Incidence is approximately 1 in 4,000 live births and has been increasing in recent decades.
• Over 90% of cases are diagnosed prenatally by ultrasound showing free-floating intestines.
• Surgical closure is required; the exposed bowel is at risk for hypothermia, fluid loss, and infection.

Pathophysiology

Gastroschisis results from a disruption in the migration of lateral ventral body folds during early embryonic development. The defect is located to the right of the umbilicus, and the herniated abdominal contents (primarily small intestine) lack any protective covering. The exposed bowel is directly bathed in amniotic fluid in utero and is vulnerable to chemical irritation, inflammation, and edema. After birth, the uncovered intestines are at immediate risk for heat loss, evaporative fluid loss, and bacterial contamination.

Clinical Manifestations

• Obvious bowel herniation through the abdominal wall defect, to the right of the umbilicus, without a covering sac.
• Bowel may appear thickened, matted, or inflamed from amniotic fluid exposure.
• Hypothermia and fluid volume deficit if not promptly managed.

Nursing Assessment

• Assess the defect size, amount of herniated bowel, and bowel condition (color, edema, integrity).
• Monitor vital signs with emphasis on temperature (hypothermia risk) and hemodynamic stability.
• Monitor fluid and electrolyte status: strict intake and output, daily weights.
• Assess for signs of bowel obstruction or ischemia (distension, bilious emesis, absent bowel sounds).
• Evaluate for associated anomalies (intestinal atresia is the most common association; cardiac defects are less common than with omphalocele).

Nursing Interventions

• Cover exposed bowel immediately with warm, sterile saline-soaked gauze and a sterile transparent barrier to prevent heat and fluid loss.
• Position the neonate on the side to prevent kinking of mesenteric blood supply.
• Maintain thermoregulation with radiant warmers and minimal exposure.
• Provide IV fluid resuscitation; the neonate will require 1.5 to 2 times the normal fluid requirements due to insensible losses.
• Maintain NPO status; provide parenteral nutrition until bowel function returns postoperatively.
• Prepare for surgical closure (primary closure or staged silo reduction depending on defect size).
• Monitor for infection: strict aseptic wound care, monitor WBC and cultures.
• Educate parents about the surgical plan and anticipated NICU course.

Related Concepts

• omphalocele - Midline abdominal wall defect with peritoneal sac covering.
• tracheoesophageal-fistula - Another congenital GI surgical emergency.
• Thermoregulation - Critical neonatal care consideration.
• fluid-electrolyte-regulation-by-organs - Significant fluid losses from exposed bowel.
• neonatal-bonding-feeding-and-newborn-screening - Early identification and stabilization.

Self-Check

1. How does gastroschisis differ from omphalocele in terms of location and protective covering?
2. Why do neonates with gastroschisis require significantly increased fluid replacement?
3. What is the immediate nursing priority when caring for a neonate born with gastroschisis?