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|Year : 1984 | Volume
| Issue : 3 | Page : 189-90
Gastroschisis in pregnancy (a case report).
Parulekar SV, Shobha , Joglekar JJ, Madhav HT
|How to cite this article:|
Parulekar S V, Shobha, Joglekar J J, Madhav H T. Gastroschisis in pregnancy (a case report). J Postgrad Med 1984;30:189
Omphalocele major and gastroschisis are conditions that can now be diagnosed antenatally with the help of an ultrasonic scan. However, routine ultrasonic scanning of all gravidae is not possible due to lack of adequate facilities in most health centres in a developing country. Hence, a number of patients with foetal, abdominal wall defects are diagnosed only after delivery and then usually with a ruptured sac. An unusual case of foetal gastroschisis with the foetus in a transverse lie is presented below for its rarity.
M.K., a 20 year old young woman, gravida 1, para 0, presented with 8 months of amenorrhoea and labour pains. Her last menstrual period had been on 10-4-1982 and the expected date of delivery on 17-1-1983. She had not attended any antenatal clinic. She was first seen at a peripheral hospital on 2-12-1982. On examination, her vital signs were found to be normal. She was in established labour beyond the possibility of arrest with tocolytic therapy. The foetus was thought to be in a longitudinal lie with cephalic presentation. Foetal heart rate was 142 beats per minute and regular.
After observation for 6 hours, the local midwife repeated the pelvic examination and found a tense, bulging sac, which she thought to be a bag of forewaters. She ruptured it with a Kocher's clamp. This was followed by prolapse of the foetal small intestine and liver out of the maternal introitus. The patient was then transferred to us for further management.
On examination at this hospital, her vital signs were within normal limits. Abdominal examination showed the uterus of 30-32 weeks' gestation, with the foetus in an oblique lie in the left dorso-anterior position. Uterine contractions were at a rate of 3 per 10 minutes with relaxation in between. There was no evidence of threatened rupture of the uterus. Foetal heart sounds were absent.
Vaginal examination showed the cervix to be 4 cm dilated and 90% effaced. Lumbar spine of the foetus was the presenting part; foetal small intestine and the liver were prolapsed outside the maternal introitus. The external surface of the prolapsed foetal viscera was devoid of adhesions or fibrin deposits. A plain radiograph of the maternal abdomen and pelvis showed the foetus to be in an oblique lie with the lumbar spine as the presenting part [Fig. 1]. The maternal pelvis was radiologically adequate.
Under general anaesthesia and with all aseptic precautions, the prolapsed foetal viscera were cut off so as to avoid introduction of infection into the maternal genital tract during further manoeuvers. The uterus was relaxed with halothane and an internal podalic version was carried out followed by breech extraction.
A male child weighing 2.15 kg was delivered. It showed a left-sided gastroschisis. Intestinal tract did not reveal any atresia. There were no other abnormalities in the newborn [Fig. 2]. The post-operative course of the patient was uneventful.
There are no case reports, in the literature, of gastroschisis or omphalocele as the presenting part, which was ruptured artificially, mistaken for forewaters. Until recently, such conditions were diagnosed only after child birth. With the advent of ultrasound, an antenatal diagnosis is now possible.
Omphalocele and gastroschisis form a group of congenital malformations with an overall incidence of 1:6600. The incidence of omphalocele is 1:5000 and that of gastroschisis is 1:50000. These defects can be corrected surgically if diagnosed early and left uninjured in the process of delivery. The incidence of other congenital malformations is about 52%. Hence in a diagnosed case, amniotic fluid analysis should be carried out for chromosomal analysis. Amniography should be combined with this procedure so that intestinal atresias can be diagnosed antenatally, which are frequently found with gastroschisis. This information would aid the paediatric surgeon in his corrective surgery.
Incidence of spontaneous rupture is high in labor and vaginal delivery.,,
Babies with unruptured omphalocele or gastroschisis are better delivered by elective casarean section in a centre well equipped for intensive neonatal care including facilities and expertise for surgical correction of the defect. The overall mortality rate is about 44%, most of which is accounted for by intra-partum rupture of the sac. Partly it is due to prematurity which is often associated with gastroschisis. Hospitalization and preventive measures for pre-term labor should reduce this factor. Training of midwives in the developing countries would diminish the incidence of such mishaps.
We thank the Dean, K.E.M. Hospital and Seth G.S. Medical College, for allowing us to publish the hospital data.
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