Horizon Interdisciplinary Journal (HIJ). ISSN: 2992-7706

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Original Article

Medical-surgical and sociodemographic aspects in

patients with gastroschisis in a Third Level Hospital

in Mexico during the period 2018-2022.

Guillermo Yanowsky-Reyes

, Elvia Ximena

Rodríguez-Frausto

, Zacnicté Viridiana

Corona-Guzmán

, Denisse Estefanía Alfaro-Castellanos , Franklin Daniel Norori-

Escobar, Arely Jaqueline Pérez Padilla , Laura Olivia Montaño-Ángeles , Nidia

Raquel Álvarez-Rosales, Carlos Oswaldo Yanowsky-González .

Hospital Civil de Guadalajara Fray Antonio Alcalde/ Servicio de Cirugía Pediátrica.

Guadalajara, Jalisco, México.

Universidad Autónoma de Sinaloa. Facultad de Medicina, Campus Doctor Carlos Alfredo

Zambada Sentíes. Culiacán, Sinaloa, México

Universidad de Guadalajara. Facultad de medicina, Centro Universitario de Tonalá.

Tonalá, Jalisco, México.

* Corresponding author: Guillermo Yanowsky-Reyes, Hospital Civil de Guadalajara Fray

Antonio Alcalde/ Servicio de Cirugía Pediátrica, Calle Hospital 278, Colonia El Retiro, C.P.

44280, Guadalajara, Jalisco, México. E-mail: gyanowsk[email protected]. 0000-0003-2891-

8561

Sent: 09/25/2023 Accepted: 12/12/2023 Published: 05/13/2024

Abstract: Introduction: Gastroschisis is a birth defect in which a hole in the abdominal wall (Belly)

lateral to the umbilicus allows the infant's intestines to be exposed, in addition to other organs such

as the stomach and liver. Objective: To obtain information on the medical-surgical approach to this

congenital anomaly, identify aspects of probable risk in the demographic areas where the pregnant

women reside, pathological and non-pathological personal history of the patients' mothers, newborns

diagnosed with gastroschisis attended from January 2018 to January 2022 and drug addictions used

in the perinatal period of the pregnant women. Method: descriptive, retrospective, retrospective,

cross-sectional, observational, epidemiological cohort study. An analysis of the clinical records of the

Antiguo Hospital Civil de Guadalajara Fray Antonio Alcalde of patients with a diagnosis of gastroschisis

attended in January 2018 to January 2022 was performed. The data were collected in Microsoft Excel

and SPSS 22 software. They were subsequently interpreted and analyzed by means of measures of

central tendency and association. Results: A sample size of 48 patients was analyzed revealing that

the prevalence of gastroschisis in the Antiguo Hospital Civil Fray Antonio Alcalde from 2018 to 2022

was 0.0089%. In addition, 83% success rate was observed in the treatment of patients with

gastroschisis in pediatric surgery, with higher prevalence in male neonates (M=55.3%, F=22%), among

others. A positive association was found with gastroschisis and exposure to environmental pollutants

(OR=1.67), teenage mothers (OR=2) and ORH+ blood group (OR=1.29). The risks by demographic area

according to their exposure and locality, 50% exposure to insecticides and 17% to polluting industries.

The diagnosis of this malformation was made in 47% in the second trimester, 28% in the first trimester

and 23% in the third trimester. Within the personal pathological and non-pathological history of the

parents, no pathology of importance was identified. Surgical management was 59.2% with deferred

Horizon Interdisciplinary Journal (HIJ). ISSN: 2992-7706

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closure and 40% with primary closure, medical management was for 100% of the patients and 16 of

them required mechanical ventilation. Conclusion: According to the results obtained, the main

positive relationship for presenting gastroschisis was the presence of a teenage mother and exposure

to environmental pollutants in the studied sample.

Key words: gastroschisis, medical-surgical approach, risk factors, gestation, complications,

demographics, teenage mother.

1. Introduction

According to the Center for Disease Control

and Prevention (CDC) definition,

gastroschisis is a birth defect in which a hole

in the abdominal (belly) wall lateral to the

navel allows the baby's intestines to remain

exposed outside the abdominal cavity

potentially containing other organs such as

the stomach and liver

. The word

Gastroschisis comes from the Greek word

"gastroschisis" (gastro means belly and

schisis means fissure, opening or

separation), coined by Taruffi in 1894

2, 3

Gastroschisis within developed countries in

North America is reported with an

incidence of 3-4.5 cases per 10,000 live

births, according to the European

Congenital Anomalies Surveillance Network

(EUROCAT), the reported incidence is 2.63

cases per 10,000 live births

There are no exact data on the incidence of

gastroschisis in Mexico, however, according

to data published by a third level hospital

the incidence varies from 1.6 to 4.6 patients

per 10,000 live births with an economic and

social impact within families with patients

affected by this pathology, most of them

being families with vulnerability factors

such as low social status (poverty), drug

addictions in the mother, drugs, maternal

age below 20 years, low schooling, short

inter-gestational period and infectious

processes during pregnancy

5-7

Gastroschisis is also associated with other

conditions that require a multidisciplinary

approach by health professionals, with up to

10-20% of newborns presenting conditions

such as intestinal atresia of 10-30%,

musculoskeletal defects, cardiac, renal,

nervous system, and other conditions

8, 9

The pathogenesis of gastroschisis occurs

during the normal development of the

abdominal wall and formation of the

intestine, which herniates through the

midline during the first stage of gestational

formation, the intestine returns to the

abdominal cavity during the 10-12 week,

producing intestinal rotation outside the

body and later fixation after its return to the

abdominal cavity, and closure of the

abdominal wall where the folding of the

cranial, caudal and 2 lateral embryonic folds

occurs. To date there is no described cause,

however, there are several theories about

the cause of this pathology among which are

mentioned: Abnormal folding of the body

wall, failure of the yolk sac and of structures

to be included in the stalk, infarction and

necrosis at the base of the umbilicus caused

by interruption of blood flow through the

vitelline artery, regression of the right

umbilical vein due to localized weakness in

the paraumbilical tissue, rupture of the

amniotic membrane at the base of the

umbilical cord, early estrogenic

thrombophilia, and interference of

thrombotic by-products with

developmental signaling

. Gastroschisis

commonly presents as a single defect, in

Horizon Interdisciplinary Journal (HIJ). ISSN: 2992-7706

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which usually the intestine remains intact,

individualizing the length of the intestine

and remembering that all of them present

intestinal malrotation. In addition, it can

present: ischemia, atresia, necrosis and

perforation. If any of these complications

occur, it is known as "complex

gastroschisis"

The medical-surgical approach is well

described, it needs to be multidisciplinary

and the current criterion is to correct the

defect once the newborn (NB) has achieved

thermal, respiratory and hemodynamic

stability, which can be primary or staged.

Classically, the usual method was to cover

the intestine with gauze moistened with

physiological solution, vaseline or lactated

Ringer's solution

. It is currently described

that covering the gauze with a plastic cover

(Vita-film) is sufficient to protect the gauze

and prevent exposure and injury to the

gauze.

The surgical techniques previously

described in the literature for abdominal

wall repair were three: primary closure,

delayed closure after silo placement and

Simil-Exit

. Currently, the correction of the

defect is based on closure without sutures,

which can be primary or deferred in stages,

where a preformed silo is placed (flexible

wound retractor), and when all the loops are

inside the cavity, they are covered with a

colloid patch (hydrocolloid inclusive

dressing). This technique allows the

reduction of associated mortality, the need

for ventilatory assistance and prolonged

fasting, resulting in cost improvement for

the medical institution, which is why it is

important to reduce the demographic

factors related to the risk of gastroschisis

There is little bibliographic evidence

compared to other pathologies, being

gastroschisis one of the most common

congenital defects. This pathology is

associated with a high morbimortality rate

in newborns and it is necessary to highlight

that its frequency is increasing according to

different bibliographies throughout the

years. Different risk factors may be hidden

by unavoidable biases in the research

already carried out, finding vulnerabilities

that this research seeks to overcome in

order to minimize the increase of cases.

The aim of the present study was to obtain

information on the medical-surgical

approach to this congenital anomaly,

identify aspects of probable risk in the

demographic areas where the pregnant

women reside, pathological and non-

pathological personal history, drug

addictions of the mothers of newborns with

gastroschisis attended from January 2018 to

January 2022.

It is a retrospective cohort study that

provides high feasibility because it does not

require high costs or many resources.

Horizon Interdisciplinary Journal (HIJ). ISSN: 2992-7706

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2.Method

The study design was epidemiological,

descriptive cohort, retrospective, cross-

sectional and observational, carried out at

the Antiguo Hospital Civil de Guadalajara

Fray Antonio Alcalde. The population of

interest were patients attended at that

institution with a diagnosis of gastroschisis.

The inclusion criteria were patients with a

diagnosis of gastroschisis, having been

attended at the Antiguo Hospital Civil de

Guadalajara Fray Antonio Alcalde from

January 2018 to January 2022, and meeting

more than four qualitative variables. Clinical

records of patients with a diagnosis of

omphalocele, incomplete records with less

than four qualitative variables, being the

product of a pregnant woman with

gastroschisis before 2018 and after January

2022, and having been treated in another

hospital outside the Antiguo Hospital Civil

de Guadalajara Fray Antonio Alcalde were

excluded.

Data collection was performed during the

months of July and August 2023. Due to

patient confidentiality, no data that could

identify the patient was recorded.

The sample size was obtained by analyzing

the clinical records of the Antiguo Hospital

Civil de Guadalajara Fray Antonio Alcalde, in

which 104 cases were derived (n=104), from

which those that met the inclusion and

exclusion criteria were selected. The type of

sampling was by consecutive inclusion, in

which the final sample was composed of 48

cases (n=48).

Once the total sample size was defined

(n=48), a database was created using Excel

office, in which quantitative variables were

included, such as gestational age, sex of the

newborn, live or stillborn, delivered alive or

dead, age of the parents, time of diagnosis of

the pregnancy (weeks of gestation), time of

diagnosis of the gastroschisis type

abdominal defect (weeks of gestation),

number of normal ultrasounds reported,

duration with assisted ventilation, duration

with orogastric tube, weight at birth and at

discharge (kg), height at birth (cm), size of

the abdominal defect (cm) and number of

gestations.

On the other hand, the qualitative variables

considered were: place of origin of both

parents, factories, polluting industries or

exposure to insecticides, education and

employment of both parents, drug

addictions of both parents, socioeconomic

level, place of birth, admission diagnosis,

birth mode (vaginal or abdominal), prenatal

complications, genitourinary infections

during pregnancy, direct cause of death,

content of the abdominal defect, medical

approach after birth (advanced neonatal

resuscitation maneuvers, days of intubation,

parenteral nutrition and presence of sepsis),

type of surgical management for closure of

the abdominal defect (primary or staged

sutureless closure), medications required

(use of antibiotics as prophylactic

management, NSAIDs and opioids), type of

feeding (parenteral nutrition, exclusive or

mixed breastfeeding), requirement of

orogastric tube, complications during the

newborn's hospital stay (hemodynamic,

gastrometabolic, ventilatory, neurologic or

infectious), complications and subsequent

recurrent pathologies.

Horizon Interdisciplinary Journal (HIJ). ISSN: 2992-7706

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Finally, for the descriptive analysis of the

quantitative and qualitative variables, a

database was created in Excel and SPSS

22, from which measures of central

tendency were obtained to represent a

centralized set of quantitative data. The

main measures reported were mean,

median and mode. On the other hand, for

qualitative variables, measures of

association were used, such as odds ratio,

prevalence, incidence and incidence rate;

the Google maps locator was used to

determine whether the pregnant women

live in demographic areas with risk

factors; in addition, the Odds Ratio

formula was used to calculate fathers and

mothers exposed and not exposed to

drug addiction before and during

pregnancy. The results are presented in

bar and pie charts depending on the type

of variable (quantitative or qualitative), as

well as tables to summarize the data.

Figure 1. Environmental risk factors as a

percentage within the demographic zone

of parents of children with congenital

gastroschisis.

In Figure 2, the place of origin of the

parents of the patients admitted with

congenital gastroschisis is shown. Of the

total sample (n=48), the origin of only 12

pregnant women is unknown, however

36 came from different areas of Jalisco

(n=12+36=48) such as Tlajomulco (n=6),

Guadalajara (n=4), Tepatitlán de Morelos

(n=3), La barca (n=1), El Salto (n=2),

Zapotlanejo (n=2), Tizapan (n=2), San

Miguel el Alto (n=1), Tenamaxtlan (n=1),

Puerto Vallarta (n=1), Jalostotitlán (n=1),

Ayutla (n=1), Cihuatlán (n=1), Unión de

Tula (n=1), Tolimán (n=1), Tlaquepaque

(n=1), Arandas (n=1), Chapala (n=1),

Zapotlán del Rey (n=1), Michoacán (n=3)

and finally Tlacuitapa (n=1).

Within these places of origin, risks were

identified by demographic zone

according to their exposure and locality.

50% of exposure to insecticides

corresponds to Tlajomulco, Tizapan,

Tepatitlán de Morelos, Jalostotitlán, and

El Cantón. The 33% of telephone

antennas corresponds to El Carmen,

Zapopan, El Campesino, Tlajomulco,

Tolimán, Tepatitlán de Morelos, Tizapan,

Cihuatlán, El Salto, Ayutla, Zapotlanejo, El

Cantón, and San Miguel el Alto. Finally,

17% of polluting industries correspond to

Tonalá, Guadalajara, Tlajomulco, El

Cantón, Tenamaxtlan, Michoacán,

Zapotlanejo, and La Barca.

Another noteworthy variable was the age

of the patients, since, as described in the

literature, it was verified by performing

the same Odds ratio method, which

yielded a result of 2, whereby those

women who have an adolescent

pregnancy are approximately twice as

likely to have their children develop

33%

17%

50%

Transmitting antennas

Industrias contaminantes

Insecticides

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gastroschisis compared to those who

decide to gestate above 20 years of age.

Figure 3 shows that the sample size

(n=48) ranges from 13 to 42 years of age,

with most of the values at the low end,

the mean is 18 years of age, pregnant

women 13 years of age (n=3), 14 years of

age (n=5), 15 years of age (n=3), 16 years of

age (n=3) and 16 years of age (n=3), 16

years of age (n=3), 17 years of age (n=7), 18

years of age (n=9), 19 years of age (n=3),

20 years of age (n=2), 21 years of age (n=5),

22 years of age (n=3), 24 years of age (n=1),

26 years of age (n=1), 27 years of age (n=1),

32 years of age (n=1), 42 years of age (n=1).

Figure 2. Place of origin of parents of

patients admitted with congenital

gastroschisis.

Figure 3. Age of pregnant women.

The diagnosis in the gestational weeks

goes from the fourth week of gestation to

the 32nd week of gestation, of these the

highest diagnostic moment of pregnancy

was at 8 weeks of gestation in 32.3%. The

gestational week in which the diagnosis

of the abdominal defect was found and

reported goes from the 16th week of

gestation to the 32nd week, where "not

reported" has a higher value than the

majority for the diagnostic moment,

followed by being found at 28 weeks of

gestation. Number of gestations of the

mothers with patients admitted for

congenital gastroschisis 53.8% reported

having been primigravida, 33.3% had

their second gestation, 7.7% went

through their fourth gestation and 5.1%

went through their third gestation. The

number of normal ultrasounds reported

prior to delivery of the pregnant women

ranged from 1 to 12 ultrasounds, with a

mean of 4.

0 2 4 6 8

Tlajomulco

Guadalajara

Tepatitlán De Morelos

La Barca

El Salto

Zapotlanejo

Tizapan

San Miguel El Alto

Tenamaxtlán

Puerto Vallarta

Jalostotitlán

Ayutla

Tolimán

Tlaquepaque

Arandas

Chapala

Zapotlán Del Rey

Michoacán

Tlacuitapa

Cihuatlán

Unión de Tula

13 14 15 16 17 18 19 20 21 22 24 26 27 32 42

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The presentation of prenatal

complications was highest for adolescent

pregnancy, being positive in 25 cases, and

in second place was exposure to

polycyclic aromatic hydrocarbons with

23 cases (none of the cases is exclusive to

each pregnant woman, since on different

occasions there were more than one

complication accompanying the

mothers). The diagnosis of this

malformation was made in 47% in the

second trimester, 28% in the first

trimester and 23% in the third trimester.

Among the pathological and non-

pathological personal histories of the

parents of the patients studied, the

following were recorded: abortion (n=1),

congenital heart disease (n=1),

cervicovaginitis (n=1), glycemic uncontrol

(n=1), diabetes mellitus (n=1), endocarditis

(n=1), hyperthyroidism (n=1), leiomyomas

(n=1), abdominal tumor (n=1), human

papillomavirus (n=1), and the rest of the

population denied any other type of

history.

In surgical management, two surgical

techniques were performed, which were

deferred closure with 59.2% (n=25) and

primary closure in 40% (n=17). In the

medical management, 100% required

orogastric tube with an average time of 14

days, the patients who required the

administration of antifungal agents (n=5),

opioids (n=39), NSAIDs (n=29) and

antibiotics (n=42). Mechanical ventilation

was required in (n=16) patients, with an

average of 4 days. And an average hospital

stay of 37 days.

Finally, the odds ratio formula of this

study was carried out to look for a

relationship between the blood serotype

of the progenitors of the product. This

formula gave us a value of 1.29, which

indicates a positive association between

the ORH+ blood group and the risk of

developing a pregnancy with problems in

the embryological period, thus ending up

with a defect of the abdominal wall of the

gastroschisis type.

Research was conducted in different

databases to reinforce that exposure to

non-ionized radiation, which is the

source emitted by antennas and

pesticides, can have significant impacts

during embryogenesis, which can end up

triggering functional congenital

malformations, such as gastroschisis, as

well as other types of damage to the

health of both pregnant women and the

general population.

Telephone antennas use non-ionized

radiation, which is electromagnetic

energy ranging from 30 to 300 kHZ. This

type of radiation is characterized because

it uses a low energetic charge, which has

been documented that it is not enough to

generate cellular alterations, however,

there are different sources that show

contrary results in which harmful effects

for health are exposed; these can alter

hormonal production, DNA, immune

system, among others

The increase in demand for mobile

devices has led the industry responsible

for these services to generate more

antennas to improve coverage17 .

Cases have been reported of genetic

damage in people living in areas close to

mobile stations compared to healthy

controls

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According to the University Environment

and Health Network, as the development

of wireless communication systems, cell

phones and the number of antennas

installed between dwellings has

increased, it has been reported in

epidemiological research journals and in

experimental laboratory models that

radio frequency radiation (RFR) at non-

thermal levels affects health. These non-

thermal exposure levels have resulted in

biological effects in humans, animals and

cells.

Exposure to RRF generates oxidative

stress in biological systems, caused by an

increase in free radicals and changes in

defense systems. Evidence of free radical

damage has been repeatedly documented

in humans, plants, animals and

microorganisms for both extremely low

frequency electromagnetic fields and

radiofrequency radiation (non-ionized).

Regarding pesticides and their relation to

congenital malformations, pesticides can

be defined as chemical substances used

in the agricultural area or at home for the

elimination or control of pests;

continuous exposure to these

biochemicals in pregnant women during

the first month can cause congenital

anomalies

According to a study on the prevalence

and risk of congenital malformation in

women exposed to pesticides, paternal

exposures may directly produce germ

cell mutation, which would be expressed

in subsequent generational

malformations due to the presence of

toxins in seminal fluids and

contamination of work clothes that may

cause secondary exposure to the

mother

21,22

Most disorders are caused by changes in

genetic information or originate from a

variety of factors23. Exposure of

pregnant women to pesticides in rural

areas is associated with the occurrence

of cases in the mother and the baby. In

the pregnant woman, research indicates

a relationship between intrauterine

exposure to pesticides and the onset of

congenital malformations

Currently, all this information is of great

impact to consider antennas and

pesticides as possible risk factors,

however, it would be ideal to search for

prospective studies in which the amount,

duration and frequency of exposure are

taken into account, this would also be

convenient to relate it to biomarker

measurements to more accurately

estimate exposure and risk

However, despite the above results, it is

necessary to consider other factors and

perform more detailed analyses to reach

stronger conclusions about the

association between these possible risk

factors and the outcome under study, as

there may be confounding factors or

biases affecting the outcome that have

not been taken into account in this

analysis.

4. Conclusion

In conclusion, this study highlights that

the obtained information from the

reviewed cases of patients diagnosed

with gastroschisis is a challenge for

public health, public awareness and

education, because positive associations

were found between risk factors, such as

the age of the pregnant person, medical

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history of the parents, drug addiction,

drugs, poor diet, socioeconomic status,

prenatal control and evolution of

pregnancy, all related to a higher risk of

developing problems in the

embryological period with the probability

of an abdominal wall defect of the

gastroschisis type. It is recommended to

strengthen timely family planning

campaigns with the objective of

preventing the consumption of toxic

substances before pregnancy to prevent

this type of embryological defects.

Management approaches and available

treatment options, such as the

development of surgical techniques, type

of nutrition, respiratory and

hemodynamic care are essential to

improve outcomes and support for

newborns affected by this congenital

defect, as well as to reduce complications

and mortality rates. Due to the size of the

sample, statistically significant results

cannot be inferred; however, according

to the results obtained, the need for

continued research with

multidisciplinary approaches to address

this congenital malformation and its

associated challenges is highlighted, as

well as the need to create awareness in

pregnant women to receive adequate

prenatal care to achieve a pregnancy with

normal evolution to culminate with a

healthy newborn and avoid possible

problems of congenital defects such as

gastroschisis.

5.Statements

5.1 Conflict of interest

The authors declare no conflict of

interest.

5.2 Funding

No funding was required to carry out the

activities.

5.3 Acknowledgments

We thank all the staff of the Pediatric

Surgery Service of the Hospital Civil de

Guadalajara Fray Antonio Alcalde for

welcoming us with open arms, providing

full support and facilities.

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