Pitfalls in the rural care of gastroschisis: A case report

Abstract

Introduction

Gastroschisis is a common congenital abdominal wall defect that requires early, specialized care to optimize long-term outcomes. In rural areas, it is crucial that rural providers and transport teams are comfortable optimizing the gastroschisis patient in the immediate post-natal period prior to arriving at a hospital with pediatric surgical care.

Case presentation

A baby born at 32 weeks gestation in a remote Indian Health Services hospital was found to have gastroschisis at delivery. Transfer to the closest pediatric hospital, over 300 miles away, was initiated. While waiting for the NICU flight team to arrive, the rural hospital team cared for the infant. The bowel wrap caused the bedding to become cold and wet, and the baby was hypothermic when the flight team arrived. The local team started an IV, but was unable to achieve additional access and gave antibiotics instead of bolus or maintenance IV fluids. The infant arrived at the children's hospital over 6 hours after birth hypothermic, acidotic, and with severe bowel matting. At the receiving hospital, the gastroschisis was managed with a preformed silo and daily reductions until the baby was appropriate for surgical closure. Complete reduction of the bowel and surgical closure of the abdominal wall was achieved at day of life 15. A sutured repair of the fascia was performed. The baby recovered well from surgery and was started on feedings five days later. A standard feeding protocol is used for infants with gastroschisis, and this infant achieved full feedings 20days after surgery. No complications of gastroschisis occurred after repair.

Conclusion

The care of babies born with gastroschisis in remote or rural centers without a definitive neonatal care team can be challenging due to lack of expertise, lack of appropriate equipment, and communication difficulties with definitive care centers during the acute incident. Collaboration with rural centers can identify areas of weakness or need which may lead to the development of a simple guideline to care for these infants.