Presentation: K.R., a 19-year-old pregnant mother with twins, presented to the Rush Fetal and Neonatal Medicine Program in January 2008, following referral from an outside hospital for an abnormal fetal ultrasound result showing protrusion of the intestines outside the abdomen. Repeat ultrasound performed by program co-director and obstetric and gynecologic ultrasound specialist Jacques Abramowicz, MD, confirmed the diagnosis of a fetal abdominal wall defect consistent with gastroschisis in twin A.
Following an initial meeting to discuss the findings, K.R., her husband and her family participated in a multidisciplinary conference with the entire clinical team participating in her case. Together, they established a prenatal care plan, a delivery care plan and a postnatal care plan. The team consisted of a perinatologist, a pediatric surgeon, a general pediatrician, a neonatologist, advanced practice nurses, a social worker and a chaplain.
Prenatal care: After consultation with the team and her referring obstetrician, K.R. transferred her prenatal care to Women’s Health Consultants at Rush because of their expertise in high-risk pregnancies. Both babies had interval assessment of fetal growth via ultrasound, with special attention to the appearance of the fetal intestines on twin A. Further assessment of fetal well-being began at 32 weeks via antenatal testing.
Delivery: The initial plan was term delivery; however, due to development of maternal pre-eclampsia, a c-section was performed at 33 weeks of gestation. Robert Kimura, MD, program co-director and attending neonatologist, Xavier Pombar, DO, perinatologist, and Ai-Xuan Holterman, MD, pediatric surgeon, assembled their respective teams to attend K.R.’s delivery. Twin A was born weighing 4 lbs. 5 oz. with gastroschisis; twin B weighed 4 lbs. 6 oz. with no abnormalities.
Twin A’s intestines had an abnormal appearance, indicating poor blood perfusion and possible intestinal volvulus. The baby was also noted to have abundant meconium-stained oral secretions, suggesting intestinal obstruction; immediate intubation to protect the airways was warranted. The intestines were rapidly detorsed and elevated with sterile saline dressings by the surgical team. This allowed perfusion, and ultimately the intestines regained normal color.
Surgical treatment: Because of concerns over the status of the intestines, the pediatric surgeon, Ai-Xuan Holterman, MD, decided to immediately proceed with surgery; the operating team was deployed within the hour. Adhesive bands causing intestinal obstruction were divided, the intestines were reduced back into the baby’s abdomen and the open abdomen was closed within hours of birth.
Conclusion: Timely antenatal diagnosis, as well as comprehensive, coordinated and expert treatment allowed prompt and effective care for two delicate pre-term babies, in particular, a fragile twin with gastroschisis. The known complications of gastroschisis — intestinal injury with the potential for loss of intestines, short gut and delayed intestinal function — were avoided. Twin Awas extubated six days following surgery. The baby tolerated initial feedings at 10 days, and was discharged four weeks later at 5 lbs. 14 oz. Twin B was discharged three weeks after pre-term delivery with no complications at 5 lbs. 4 oz.
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