Neonatal demise from a complex abdominal wall defect in a low-resource setting: A case study on the consequences of a fractured perinatal care cascade

Abstract

Survival for neonates with abdominal wall defects (AWDs) exceeds 90% in high-income countries, yet mortality remains devastatingly high in many low-resource settings. This profound survival disparity reflects systemic deficiencies in the perinatal care cascade. We present a case of a preterm neonate with a complex AWD to exemplify the catastrophic consequences when this continuum of care is fragmented. A 32-year-old multiparous woman presented at 28 weeks gestation. Prenatal ultrasound identified a live fetus with a large, complex AWD; findings were ambiguous, with features suggestive of both gastroschisis (free-floating bowel) and a ruptured omphalocele (significant liver herniation, suggestion of a partial membrane). After counseling, she was referred for tertiary care, but transfer was not feasible due to systemic barriers. Two weeks later, at 30 weeks gestation, she presented in advanced preterm labor and delivered vaginally. The 1.5 kg male neonate was born without spontaneous cardiorespiratory activity (Apgar scores of 0 at 1 and 5 minutes) and had a large paraumbilical defect with massive evisceration of the liver and intestines. Resuscitation was unsuccessful. This case demonstrates that neonatal mortality from complex congenital anomalies in resource-limited environments is often a consequence of health system failures rather than an inevitability of the pathology itself. The diagnostic ambiguity of the defect was clinically secondary to the critical, sequential breakdowns in the care cascade: the inability to enact a timely transfer to a tertiary center for planned delivery and immediate access to pediatric surgical and neonatal intensive care. This outcome underscores the imperative to strengthen referral pathways, build capacity for specialized perinatal services, and invest in regionalized care to address the stark global inequities in survival for treatable congenital conditions.