Meconium peritonitis: prenatal diagnosis, postnatal management and outcome

The Role of Prenatal Ultrasound Examination in Predicting the Outcomes of Ovarian Fetal Cysts: A Pictorial Essay

Objectives: The aim of this study was to evaluate prenatal ultrasound features, fetal postnatal outcomes, and the need for postnatal surgery in the suspicion of ovarian torsion. Methods: We included patients with a singleton pregnancy with a suspicion of ovarian fetal cyst referred to our center. Data derived from prenatal ultrasound evaluations, delivery, and postnatal follow-up were then extracted from the hospital registers. Results: The ultrasound features of 32 fetal ovarian cysts and related neonatal outcomes were analyzed. The mean gestational age at diagnosis was 32 weeks (28-36), while the mean diameter of the cyst diagnosis was 34.8 ± 13.2 mm. In 78.1% of cases, the cysts did not change their characteristics during pregnancy, while in 9.4%, they increased their dimensions, and in 12.5%, they reduced their size. In 78.1% of cases, the diagnosis was confirmed postnatally, and in 40% of cases, a spontaneous regression occurred during follow-up. Surgery was performed in 60% of cases, and most of the time (66.7%), an adnexectomy was required. Conclusions: An unfavorable outcome was associated with cystic dimensions and ultrasound feature modifications during pregnancy. However, our study demonstrated that a hemorrhagic content is not always indicative of adnexal torsion, and spontaneous resolution may occur. In addition, only a few of the simple anechoic cysts managed surgically presented with necrosis at histopathological examination; therefore, a conservative approach might be proposed in those cases.

Ultrasound microvascular flow imaging: evaluating fetal mesenteric blood flow and predicting postnatal surgery in meconium peritonitis

OBJECTIVE

This study explored the characteristics of fetal mesenteric blood flow perfusion across various gestational weeks and evaluated the efficacy of Microvascular Flow (MV-Flow) imaging technology in assessing intestinal wall blood flow in fetuses with meconium peritonitis (MP).

METHOD

In this retrospective study, we analyzed 35 fetuses with MP and 160 healthy fetuses. We examined the correlation between the Vascular Index (VI) of mesenteric perfusion and gestational age, conducted an analysis comparing MP operative and non-operative groups, and developed a predictive model for surgical intervention.

RESULTS

The VI value demonstrated no significant change with increasing gestational age (correlation coefficient = 0.005, p = 0.946). For healthy fetuses, VI ranged approximately from 34.66% to 67.26% using the automatic ellipse method. The MP operative group exhibited significantly more cesarean deliveries (100% vs. 52.9%, p = 0.003), shorter gestational periods (34.76 ± 2.16 weeks vs. 37.48 ± 1.55 weeks, p < 0.001), lower birth weights (2762.14 ± 452.76 g vs. 3225.88 ± 339.98 g, p = 0.003), more persistent ascites (92.9% vs. 52.9%, p = 0.021), more frequent intestinal wall echo reductions (57.1% vs. 5.9%, p = 0.004), and lower VI (18.57 ± 5.51% vs. 39.41 ± 7.02%, p < 0.001). A predictive model was established: Logit (P)=8.86 - (0.37* VI) + (1.49* ascites), yielding an area under the curve of 0.857, with 78.6% sensitivity and 88.2% specificity. The VI value was significantly associated with the need for postnatal surgery (OR = 0.689, 95% confidence interval: 0.511 - 0.929, p = 0.015). A Receiver Operating Characteristic curve analysis for VI in predicting postnatal surgery showed an area under the curve of 0.971, with an optimal cutoff value of 35%, achieving 91% sensitivity and 94.4% specificity.

CONCLUSION

MV-Flow imaging effectively quantified fetal bowel wall blood flow perfusion. There was no significant change in VI across different gestational weeks. Significantly lower VI values in MP fetuses indicated an increased risk of intestinal wall necrosis and the potential need for postnatal surgical intervention.

The importance of prenatal diagnosis for the surgical strategy of giant cystic meconium peritonitis: A case report

Background

Giant cystic meconium peritonitis (MP) is a relatively rare entity. Prompt surgical treatment is required to manage the underlying etiology and reestablish the continuity of the intestines. Despite perinatal and postoperative care improvements, the overall mortality rate is still relatively high. We reported a giant cystic MP that was recognized using antenatal sonography (US). It was successfully treated with primary anastomosis.

Case presentation

We presented a female newborn with a chief complaint of abdominal mass. The prenatal sonography showed an intraabdominal cyst at the 28th week of gestation. She was born at the gestational age of 38 weeks via vaginal delivery from a primigravid mother without complications, with a birth weight of 3275 g. Elective surgery was performed at the age of eight days, and a calcified 10 cm cyst was revealed along with severe adhesions. The cyst was found to communicate with the ileum located 30 cm proximal from the ileocecal junction. No malrotation and volvulus were found. The cyst and a portion of the ileum were resected, followed by a primary end-to-end anastomosis. Pathologic examination showed necrotic tissue lined with epithelial tissue with microcalcifications containing bilirubin pigments, consistent with cystic MP. The patient has uneventfully discharged on postoperative day 17. The patient has normal growth and development, except for delayed walking, at the last follow-up of two years of age.

Conclusion

Giant cystic MP is a rare disorder that can be detected early using the antenatal US. Our case highlights the importance of early diagnosis for giant cystic MP using the antenatal US leads to prompt surgical treatment and a more favorable prognosis.

Meconium peritonitis: A 22-year review in a tertiary referral center

BACKGROUND

Meconium peritonitis (MP) is a sterile, chemical peritonitis resulting from in-utero fetal bowel perforation. Severe cases may lead to serious morbidities and mortalities.

OBJECTIVE

To review the common antenatal ultrasound abnormalities associated with MP, and identify radiological and clinical prognostic factors.

MATERIALS AND METHODS

Retrospective review of all neonates with MP from January 1997 to December 2019 treated in our hospital was performed. Antenatal ultrasound findings, clinical presentations and outcomes were analyzed.

RESULTS

Thirty-five neonates (17 males, 18 females) were included in the study. Thirty-two (91.4%) attended antenatal screening, and 27 (84.4%) of them had abnormalities identified on antenatal ultrasound. The most common abnormality was polyhydramnios (43.8%). Nineteen (54.3%) patients were inborn. Twenty (57.1%) patients were born prematurely. Laparotomy was required in 85.7% of patients. The median time to laparotomy was shorter in the inborn group [1 day (0-9 days) vs 4 days (2-34 days), p = 0.001], but the duration of post-operative hospital stay was comparable [71 days (16-423 days) vs 73.5 days (23-231 days)]. However, such duration was found to be significantly longer in the pre-term group when compared to full-term [58.5 days (16-89 days) vs 85 (21-423 days), p = 0.01]. The most common pathology was small bowel atresia and there were two mortalities.

CONCLUSION

Due to the advancement in prenatal detection, pediatric anesthesia, intensive care and surgical techniques, the morbidity and mortality of MP has much decreased. Effective multi-disciplinary antenatal counseling facilitated the perinatal management of MP and resulted in comparable prognosis and outcome in inborn and outborn neonates.

Fetal Meconium Peritonitis - Prenatal Findings and Postnatal Outcome: A Case Series, Systematic Review, and Meta-Analysis

PURPOSE

 To describe the postnatal outcome of fetal meconium peritonitis and identify prenatal predictors of neonatal surgery.

METHODS

 We retrospectively reviewed all fetuses with ultrasound findings suspicious for meconium peritonitis at a single center over a 10-year period. A systematic review and meta-analysis were then performed pooling our results with previous studies assessing prenatally diagnosed meconium peritonitis and postnatal outcome. Prenatal sonographic findings were analyzed to identify predictors for postnatal surgery.

RESULTS

 34 cases suggestive of meconium peritonitis were diagnosed at our center. These were pooled with cases from 14 other studies yielding a total of 244 cases. Postnatal abdominal surgery was required in two thirds of case (66.5 %). The strongest predictor of neonatal surgery was meconium pseudocyst (OR [95 % CI] 6.75 [2.53-18.01]), followed by bowel dilation (OR [95 % CI] 4.17 [1.93-9.05]) and ascites (OR [95 % CI] 2.57 [1.07-5.24]). The most common cause of intestinal perforation and meconium peritonitis, found in 52.2 % of the cases, was small bowel atresia. Cystic fibrosis was diagnosed in 9.8 % of cases. Short-term neonatal outcomes were favorable, with a post-operative mortality rate of 8.1 % and a survival rate of 100 % in neonates not requiring surgery.

CONCLUSION

 Meconium pseudocysts, bowel dilation, and ascites are prenatal predictors of neonatal surgery in cases of meconium peritonitis. Fetuses with these findings should be delivered in centers with pediatric surgery services. Though the prognosis is favorable, cystic fibrosis complicates postnatal outcomes.

Fetal magnetic resonance imaging contributes to the diagnosis and treatment of meconium peritonitis

BACKGROUND

Meconium peritonitis (MP) is a rare fetal disease that needs to be urgently identified for surgical intervention. We report a series of 35 patients diagnosed prenatally with MP by magnetic resonance imaging (MRI), illustrate the imaging findings and investigate the predictive value of these findings for postpartum management.

METHOD

A consecutive cohort of patients diagnosed with MP who were born at our institution from 2013 to 2018 was enrolled retrospectively. The prenatal ultrasound and MRI findings were analyzed. Fisher's exact probability test was used to evaluate the predictive value of MRI for surgical intervention between the operative group and the nonoperative group.

RESULTS

Ascites (30/35) and distended bowel loops (27/35) were two of the most common prenatal MP-related findings on fetal MRI. Of the 35 infants, 26 received surgical intervention. All fetuses with MRI scans showing bowel dilatation (14/26, p = 0.048) and micro-colorectum (13/26, p = 0.013) required surgery. There were no significant differences in the number of fetuses with meconium pseudocysts and peritoneal calcifications between the two groups.

CONCLUSION

Fetuses with bowel dilatation and micro-colorectum on MRI may need postpartum surgical intervention. Infants with only a small amount of ascites and slight bowel distention were likely to receive conservative treatment.

Massive ascites and severe pulmonary hypoplasia in a premature infant with meconium peritonitis and congenital cytomegalovirus infection

Background: Meconium peritonitis (MP) is an infrequent prenatal complication. Association between MP and pulmonary hypoplasia has never been reported. Case Report: A female infant with antenatally diagnosed MP and ascites was delivered at 36 gestational weeks. She died shortly after birth due to pulmonary insufficiency. Autopsy confirmed the presence of MP and ascites, and additionally revealed intestinal malrotation, volvulus, necrosis and perforation, and pulmonary hypoplasia. Congenital cytomegalovirus (CMV) infection was also noted. This was an unexpected finding as the mother was tested negative for CMV IgM at 26 gestational weeks after sonographic detection of fetal ascites. Conclusions: This is the first reported case of lethal pulmonary hypoplasia in a neonate with MP-associated ascites complicated by congenital CMV infection. This case illustrates that a negative maternal CMV IgM might not be sufficient to rule out congenital CMV, and that a concomitant infectious etiology should always be considered even when a primary cause for fetal ascites (e.g., MP in this case) is identified.

Predicting poor outcomes and the need for surgical treatment in neonates with meconium peritonitis

OBJECTIVE

The objective of this study is to determine factors associated with poor outcomes and the need for surgical treatment in neonates with meconium peritonitis (MP).

METHODS

We evaluated the association between prenatal ultrasound features, maternal characteristics, and the likelihood of surgery, mortality, and serious morbidity in 49 neonates with a prenatal diagnosis of MP, who were born in Guangzhou Women and Children's Medical Center between January 2011 and December 2016.

RESULTS

Thirty of 49 neonates (61.2%) required surgical treatment, and 17 (34.7%) had a poor outcome. Independent predictors of need for surgical treatment were polyhydramnios, maternal intrahepatic cholestasis of pregnancy (associated with lower risk), and persistence of peritoneal fluid. The model correctly predicted 70.0% of the neonates who required surgery (at a 10% false-positive rate; area under the curve [AUC]: 0.86 [95% CI, 0.75-0.97]). For poor outcomes, independent predictors were low gestational age at birth, persistence of peritoneal fluid, and polyhydramnios. For the latter, the model only achieved a detection rate of 52.9% (10% false-positive rate, AUC: 0.82 [95% CI, 0.70-0.94]).

CONCLUSIONS

A combination of prenatal ultrasound features and maternal characteristics correctly predicted 70.0% the need for neonatal surgery. Prediction of poor outcome-based prenatal ultrasound features and gestational age did not perform well.

Meconium peritonitis: the role of postnatal radiographic and sonographic findings in predicting the need for surgery

BACKGROUND

The role of imaging in meconium peritonitis is not limited to establishing a diagnosis; rather, it might also be helpful in determining which neonates require surgery. However, few data in the literature correlate the postnatal radiographic and sonographic findings with the need for surgery.

OBJECTIVE

To compare the role of postnatal radiographic and sonographic findings in predicting the need for surgery in neonates with meconium peritonitis.

MATERIALS AND METHODS

We conducted a retrospective analysis of clinical, imaging and surgical findings in all neonates with meconium peritonitis in the period 1999-2014. We divided the children into operative or non-operative groups and then correlated each group with the presence or absence of the following findings on both the radiographs and sonograms: peritoneal calcification, meconium pseudocyst, intestinal obstruction, volvulus, ascites and pneumoperitoneum.

RESULTS

Thirty-seven neonates (22 males, 15 females) had meconium peritonitis in this period, of whom 23 (62%) required surgery and 14 (38%) were successfully treated non-surgically. None had an antenatal infection and three had cystic fibrosis (8%). Bowel obstruction identified on radiography (12/23, P=0.01) and sonography (9/23, P=0.04) and ascites identified with sonography (7/23, P=0.01) were associated with the need for surgical intervention. The presence of pneumoperitoneum and volvulus were also associated with surgical intervention. There was no significant statistical difference in the number of neonates with diffuse peritoneal calcification who were treated operatively or non-operatively. Four (33%) of the 12 neonates with meconium pseudocysts were successfully treated non-operatively.

CONCLUSION

Imaging findings that predicted the need for surgery were intestinal obstruction, ascites, volvulus and pneumoperitoneum. Neonates with meconium pseudocysts did not require surgery if they were not associated with the described findings. The findings in our patients also indicate that those with diffuse peritoneal calcification as an isolated finding can be successfully treated non-operatively.

Cystic meconium peritonitis with jejunoileal atresia: Is it associated with unfavorable outcome?

AIM

To compare the outcome between patients with jejunoileal atresia (JIA) associated with cystic meconium peritonitis (CMP) and patients with isolated JIA (JIA without CMP).

METHODS

A retrospective study was conducted for all neonates with JIA operated in our institute from January 2005 to January 2016. Demographics including the gestation age, sex, birth weight, age at operation, the presence of associated syndrome was recorded. Clinical outcome including the type of operation performed, operative time, the need for reoperation and mortality were studied. The demographics and the outcome between the 2 groups were compared.

RESULTS

During the study period, 53 neonates had JIA underwent operation in our institute. Seventeen neonates (32%) were associated with CMP. There was no statistical difference on the demographics in the two groups. Patients with CMP had earlier operation than patients with isolated JIA (mean 1.4 d vs 3 d, P = 0.038). Primary anastomosis was performed in 16 patients (94%) with CMP and 30 patients (83%) with isolated JIA (P = 0.269). Patients with CMP had longer operation (mean 190 min vs 154 min, P = 0.004). There were no statistical difference the need for reoperation (3 vs 6, P = 0.606) and mortality (2 vs 1, P = 0.269) between the two groups.

CONCLUSION

Primary intestinal anastomosis can be performed in 94% of patients with JIA associated with CMP. Although patients with CMP had longer operative time, the mortality and reoperation rates were low and were comparable to patients with isolated JIA.

Unusual association of brain hemorrhage and digestive tract occlusion: about two prenatal cases

We report two prenatal cases of an exceptional association of digestive tract atresia or perforation with brain hemorrhage. This combination worsens the prognosis leading to termination of pregnancy in one case. We outline the importance of a careful fetal brain examination on imaging in cases of prenatal “acute” abdominal insults.

Meconium peritonitis: Prenatal diagnosis of a rare entity and postnatal management

The aims of this study were to review our therapy and outcome for meconium peritonitis (MP) patients, and to clarify predictors of postoperative morbidity and mortality. We retrospectively reviewed a total 15 patients with MP who received surgical intervention at our institute from December 1990 to November 2012. Diagnosis of MP was confirmed by operative findings. We analyzed the relationship between outcome and patients' factors including patients' characteristics, prenatal diagnosis, type of MP, general condition, and surgical procedure. There was no relationship between outcome and the following factors: gender, gestational age, body weight at birth, delivery type, Apgar score, prenatal diagnosis, types and causes of MP, and surgical procedure. However, the preoperative presence of circulation deficiency and serum CRP values were statistically significant predictors of outcome in our MP patients. Prenatal diagnosis is essential for the first step of perinatal therapy for MP. Surgical strategy should be selected according to the information of prenatal diagnosis. Early surgical procedures to reduce systemic and abdominal inflammation just after birth may improve the outcome of severe MP cases.

Meconium peritonitis in both fetuses with early twin-to-twin transfusion syndrome

Twin-to-twin transfusion syndrome (TTTS) is due to unbalanced inter-twin bloodflow through placental vascular anastomoses. We present a TTTS case treated with fetoscopic laser photocoagulation (FLP) that was complicated by perinatal meconium peritonitis in both twins. Ten weeks following laser treatment, the two fetuses showed intra-abdominal hyperechogenicity and ascites. After birth, the two newborns were surgically managed for peritonitis. We discuss the pathogenesis of this double insult. The present case highlights the role of end-circulation bowel thrombi as the potential cause of subsequent intestinal perforation.

Primary anastomosis for meconium peritonitis: first choice of treatment

PURPOSE

Newborn surgery for meconium peritonitis (MP) is sometimes very difficult owing to severe adhesions and bleeding. The aim of this study was to reveal the benefit of primary anastomosis (PA) for MP by comparing PA with multistep operations (MO).

PATIENTS AND METHODS

We retrospectively reviewed 38 patients with MP who underwent surgery in our institution from 1983 to 2009. From 1983 to 2000, we essentially used MO. After 2001, we used PA with the exception of 1 patient. We performed MO on 20 patients (group A) and PA on 18 patients (group B).

RESULTS

Mortality was 4 in 20 in group A and 1 in 18 in group B. Three patients in group A and 2 in group B required reoperation because of complications. After 2001, 14 of 16 patients underwent PA. Of the 2 patients for whom PA could not be performed, one was postresuscitation from cardiopulmonary arrest and the other was an extremely low-birth-weight infant. The only mortality among the patients who underwent PA occurred in a very low-birth-weight infant who died from intraoperative hepatic hemorrhage.

CONCLUSION

PA can be performed for almost all patients with MP except for extremely low-birth-weight infants.

Interleukin 6 and interleukin 8 play important roles in systemic inflammatory response syndrome of meconium peritonitis

PURPOSE

Meconium peritonitis is caused by an intestinal perforation that may occur in the fetus, followed by severe chemical peritonitis, resulting in high morbidity.

METHODS

We have experienced six patients with meconium peritonitis. Cystic drainage was performed soon after birth for all patients. We investigated the concentrations of several cytokines and a chemokine (interleukin 8) in the ascites from the six patients with meconium peritonitis. In two patients we also measured the serum cytokines and chemokine level just after birth.

RESULTS

Interleukin 6 and interleukin 8 concentrations were very high in the cyst or ascites just after birth. In the serum taken from two patients, the levels of interleukin 6 and interleukin 8 were also high. In five patients who underwent drainage of cysts after birth, systemic inflammation could not be completely suppressed before curative surgery.

CONCLUSIONS

Interleukin 6 and interleukin 8 play important roles in the inflammatory response syndrome associated with meconium peritonitis, and drainage of cystic fluid did not completely suppress this inflammation. To lessen the high morbidity of meconium peritonitis, efforts should be made to suppress the inflammatory response using new treatment strategies, such as administration of steroids or anti-cytokine therapy to supplement cystic drainage.

A case of massive meconium peritonitis in utero successfully managed by planned cardiopulmonary resuscitation of the newborn

We report a case of emergent massive meconium peritonitis due to intrauterine volvulus without malrotation. Fetal ascites was detected on a regular ultrasonographic examination, and fetal distress was found on cardiotocographic monitoring. The mother had noticed a slight decrease in fetal movements over the preceding 24 hours. Prenatal magnetic resonance imaging allowed us to distinguish the meconium from fetal peritoneal fluid and to evaluate the degree of compression of the fetal thoracic cavity. The infant was delivered by emergency cesarean section and demonstrated tense abdominal ascites with edema at birth. She required cardiopulmonary resuscitation and immediate paracentesis.

Gastrointestinal pathology in neonates: new imaging strategies

The mainstay of imaging of gastrointestinal (GI) pathology in infants has always been and still is the plain radiograph of the abdomen and conventional contrast studies. In this review emphasis is placed on the situations where there are new imaging strategies and alternative modalities of imaging, including US, CT, MRI and radionuclide studies. This review will deal with GI pathology in the newborn and in the older neonate. It will also refer to any new approaches to imaging GI pathology in the premature infant. Finally the review will address how antenatal diagnosis of gastrointestinal tract abnormalities has changed the imaging strategy and management of the neonate.

Prenatal diagnosis and postnatal management of meconium peritonitis

BACKGROUND

Meconium peritonitis (MP) is a rare prenatal condition that leads to substantial neonatal morbidity and mortality.

PATIENTS AND METHODS

All patients between 1998 and 2006 referred for prenatal diagnosis were retrospectively analyzed for diagnosis of MP. Prenatal ultrasound findings were compared with postnatal etiology, intraoperative findings, and postnatal outcome of the patients.

RESULTS

Antenatal MP was diagnosed in 14 fetuses between 18 and 38 weeks' gestation. The prenatal diagnosis of MP was confirmed by clinical and radiological findings in 8 (62%) of 13 infants born alive. All patients were delivered preterm between 33 and 36 weeks' gestation by cesarean section. Urgent neonatal surgery for treatment of bowel obstruction was required in all eight infants. Prenatal ultrasound diagnosis of bowel dilatation was the only variable found to be associated with the need for subsequent surgical intervention (P=0.02).

CONCLUSIONS

Clinical outcome of MP diagnosed antenatally can be either mild or severe form. The underlying cause of severe MP is heterogeneous and neonatal surgery was always required.

Ileal atresia with meconium peritonitis: fetal MRI evaluation

We report a case of ileal atresia with meconium peritonitis evaluated by fetal MRI. Prenatal ultrasounds in the third trimester initially demonstrated a cystic abdominal mass that resolved with development of dilated bowel loops. Fetal MRI at 32 weeks gestation identified a perihepatic collection with several dilated small bowel loops and normal sized meconium filled rectosigmoid consistent with distal bowel perforation and loculated meconium peritonitis. Following delivery, the infant presented with bowel obstruction. Contrast enema revealed a normal sized rectosigmoid with small ascending and transverse colon. A distal ileal atresia type IIIa was documented at surgery.

Tumours of the fetal body: a review

Tumours of the fetal body are rare, but lesions have been reported in all spaces, especially in the mediastinum, the pericardial space, the adrenals, the kidney, and the liver. Lymphangioma and teratoma are the commonest histological types encountered, followed by cardiac rhabdomyoma. Adrenal neuroblastoma is the commonest malignant tumour. Imaging plays an essential role in the detection and work-up of these tumours. In addition to assisting clinicians it also helps in counselling parents. Most tumours are detected by antenatal US, but fetal MRI is increasingly used as it brings significant additional information in terms of tumour extent, composition and complications.

Meconium pseudocyst: a classical and successfully treated case

Meconium peritonitis with pseudocyst formation is rare and can be lethal. We report a newborn infant with antenatal sonographic diagnosis of bowel dilatation and giant meconium pseudocyst. Postnatal presentation included a palpable abdominal mass and abdominal distention. Abdominal X-ray revealed a huge egg-shell calcified mass containing air-fluid level. Postnatal sonography revealed a cystic mass with air-fluid level and acoustic shadows. Computed tomography showed a giant communicating cyst with egg-shell calcification, which compressed the other intestinal loops to the posterior peritoneal cavity. Elective laparotomy was performed, and distal ileal atresia with sealed proximal perforation and a giant meconium pseudocyst were found. Resection of the involved small bowel, including the giant pseudocyst, followed by primary end-to-end anastomosis was performed smoothly. The postoperative course was uneventful. Advances in perinatal intensive care mean that neonates can be operated upon under stable rather than critical conditions, and elective rather than emergency laparotomy, and primary anastomosis of the intestine rather than staged enterostomy can be performed.

Clinical manifestations in infants with symptomatic meconium peritonitis

BACKGROUND

Meconium peritonitis (MP) develops when bowel perforation occurs in utero or soon after birth, resulting in leakage of meconium into the peritoneal cavity. The clinical features are often variable and prenatal ultrasonography plays an important role in prenatal diagnosis.

METHODS

We conducted a retrospective review of neonates diagnosed with MP in our hospital from January 1998 to December 2007. Prenatal examinations, postnatal presentations, investigations, management, patient outcomes, and possible causes were analyzed.

RESULTS

Ten patients (five boys, five girls) diagnosed with MP were studied. The most common prenatal ultrasonographic finding was fetal ascites (7/10, 70%), followed by polyhydramnios (3/10, 30%), bowel dilatation (3/10, 30%), intra-abdominal calcification (1/10, 10%), and hydrops fetalis (1/10, 10%). Two of our patients were completely normal on prenatal ultrasonography. Only one MP diagnosis (1/10, 10%) was definitely confirmed by prenatal ultrasonography due to the presence of ascites, bowel perforation and intra-abdominal calcification. Nine patients (90%) required surgical intervention because of bowel perforation (5), bowel atresia (2), obstruction due to ileus (1), and intussusception (1). Peritonitis was of cystic type in one case (10%), fibroadhesive in five cases (50%), and generalized in four cases (40%). All 10 patients survived without long-term gastrointestinal complications.

CONCLUSION

Prenatal ultrasonography can be diagnostic for MP, which should be considered in the differential diagnosis of patients presenting with ascites or abdominal distension at birth. Close observation of postnatal clinical manifestations and timely surgical intervention resulted in a high survival rate and favorable outcome in these patients at our hospital.

An unusual cause of meconium peritonitis in a foetus

Meconium peritonitis is a sterile chemical peritonitis resulting from intestinal perforation in-utero. We present a preterm male neonate weighing 1820 g in whom foetal meconium peritonitis was diagnosed by antenatal utrasonogram. Examination of the newborn in the immediate postnatal period revealed a firm lump of size 5 x 3 cm in the right lumbar and umbilical area. Rest of the abdomen was normal without any clinical evidence of intestinal obstruction. X-ray of abdomen done at 3 hours of life showed a cystic mass with calcified margin. Ultrasonography of abdomen ruled out any definite cause of intestinal obstruction and perforation. He was kept on conservative management. At 11 hours of life the neonate passed a small sticky white mucus plug per rectum followed by black colored meconium of normal consistency 2 hours later. The bowel habit remained regular thereafter. Screening for intrauterine infections and cystic fibrosis was negative. He is under regular follow-up and is now 6 months old with normal bowel habit. A lump of size 2 x 2 cm is still palpable and a small calcified mass is persistent in x-ray. Role of an intestinal mucus plug as the potential factor for intestinal obstruction and subsequent perforation has been highlighted in the present case.

Meconium peritonitis in utero---the value of prenatal diagnosis in determining neonatal outcome

OBJECTIVE

Meconium peritonitis (MP) is a chemical peritonitis caused by fetal intestinal perforation in utero. Its incidence is rare, but serious neonatal morbidity or even mortality can occur if the diagnosis is not made until after birth. Prenatal diagnosis is important in prompting early postnatal surgical intervention, and so improving neonatal outcome.

MATERIALS AND METHODS

Fourteen cases diagnosed in utero with MP from January 1996 to December 2005 were enrolled in this study. The final diagnoses were established by surgical findings or postnatal radiography. The prenatal ultrasound features, neonatal birth characteristics, surgical findings, postnatal management and neonatal outcomes were reviewed.

RESULTS

All infants received follow-up care at our hospital. Prenatal ultrasound findings included fetal ascites (100%), intra-abdominal calcification (93%), dilated bowel loops (57%), pseudocysts (29%), and polyhydramnios (50%). Four infants (4/14; 28.5%) did not undergo postnatal surgery, but survived well. The mean gestational age at detection was significantly earlier in the non-surgery group (23+/-3.6 weeks) than in the surgery group (31.7+/-2.5 weeks). One infant (7.1%) died because of sepsis after two neonatal operations. The overall survival rate was 92.9%.

CONCLUSION

MP can be diagnosed by prenatal ultrasound, and the neonatal outcome is favorable. Early detection is not associated with poor neonatal outcome, and selective termination is unnecessary. Resolution of dilated bowel loops and polyhydramnios predict a low rate of postnatal surgical intervention.

Prenatal detection of the cystic form of meconium peritonitis: no issues for delayed postnatal surgery

Prenatal ultrasound (US) diagnosis and postnatal outcome are reviewed in three babies with the complex form of meconium peritonitis (MP), the cystic type. Perinatal management is discussed. Large intra-abdominal cysts with signs of calcifications were detected during the second mid-trimester. Meconium ascites and polyhydramnios appeared between 32 and 35 weeks of gestation. Signs of anaemia were assessed on median cerebral artery peak systolic velocity. Sudden appearance of hydrops and anaemia required preterm delivery, neonatal resuscitation and urgent abdominal drainage. Postnatal US imaging confirmed prenatal sonographic evidence. Abdominal X-ray showed calcifications and no free abdominal air. Intestinal diversion was performed in two patients on their first day of life and evolution was uneventful. Hospital death occurred in one baby, who was submitted to delayed surgery due to unstable hemodynamic conditions. Distal ileal perforation walled off by pseudocysts was detected in all cases. One baby was found to be affected by cystic fibrosis. Ileal intussusception was described in the non-surviving infant. The cystic type of MP may have a potentially rapid lethal course and the onset of foetal anaemia and polyhydramnios is a bad prognostic factor. Severe evolution in hydrops and foetal distress may occur at any moment suggesting the persistence of a leakage or re-rupture of the cysts with new meconium spillage into the abdomen. Prenatal detection of ascites, polyhydramnios and pseudocysts requires a strict follow-up, and timing of delivery has to be planned in a tertiary centre. Postnatal radiological imaging does not offer further information over prenatal imaging and surgical decision should not be influenced by the absence of abdominal free air. Urgent abdominal drainage at birth, followed by intestinal diversion of persistent intestinal perforation on the first day of life, may prevent bacterial colonisation and improve prognosis.

Prenatal detection of the cystic form of meconium peritonitis: no issues for delayed postnatal surgery

Prenatal ultrasound (US) diagnosis and postnatal outcome are reviewed in three babies with the complex form of meconium peritonitis (MP), the cystic type. Perinatal management is discussed. Large intra-abdominal cysts with signs of calcifications were detected during the second mid-trimester. Meconium ascites and polyhydramnios appeared between 32 and 35 weeks of gestation. Signs of anaemia were assessed on median cerebral artery peak systolic velocity. Sudden appearance of hydrops and anaemia required preterm delivery, neonatal resuscitation and urgent abdominal drainage. Postnatal US imaging confirmed prenatal sonographic evidence. Abdominal X-ray showed calcifications and no free abdominal air. Intestinal diversion was performed in two patients on their first day of life and evolution was uneventful. Hospital death occurred in one baby, who was submitted to delayed surgery due to unstable hemodynamic conditions. Distal ileal perforation walled off by pseudocysts was detected in all cases. One baby was found to be affected by cystic fibrosis. Ileal intussusception was described in the non-surviving infant. The cystic type of MP may have a potentially rapid lethal course and the onset of foetal anaemia and polyhydramnios is a bad prognostic factor. Severe evolution in hydrops and foetal distress may occur at any moment suggesting the persistence of a leakage or re-rupture of the cysts with new meconium spillage into the abdomen. Prenatal detection of ascites, polyhydramnios and pseudocysts requires a strict follow-up, and timing of delivery has to be planned in a tertiary centre. Postnatal radiological imaging does not offer further information over prenatal imaging and surgical decision should not be influenced by the absence of abdominal free air. Urgent abdominal drainage at birth, followed by intestinal diversion of persistent intestinal perforation on the first day of life, may prevent bacterial colonisation and improve prognosis.

Experience with meconium peritonitis

BACKGROUND

Meconium peritonitis is a sterile chemical peritonitis resulting from intrauterine bowel perforation. With the development of neonatal care, the prognosis of meconium peritonitis improved much. We report our clinical experience.

METHODS

The medical records of patients with meconium peritonitis admitted to the Asan Medical Center from June 1989 to July 2006 were retrospectively reviewed.

RESULTS

Of 41 patients (17 males, 24 females), 38 (92.7%) were suspected to suffer from meconium peritonitis prenatally, at a median gestational age of 32 weeks (range, 21-40 weeks). The most common prenatal sonographic finding was fetal ascites followed by dilated bowel. Ten patients were managed conservatively, but 31 patients underwent operations including resection and anastomosis (22), drainage procedure (4), ileostomy (3) and primary repair (2). The operative 31 cases comprised generalized (16), fibroadhesive (10), and cystic types (5). The main causes were intestinal atresia and idiopathic bowel perforation. The mortality rate was 2.4%, and the morbidity rate was 34.1%.

CONCLUSIONS

Good survival rate was achieved. But there was rather high morbidity. More gentle and delicate approach should be done to lower the morbidity.

Prenatal MR imaging of a meconium pseudocyst extending to the right subphrenic space with right lung compression

Meconium pseudocyst results from a loculated inflammation occurring in response to spillage of meconium into the peritoneal cavity after a bowel perforation. Certain cystic lesions, such as abscesses and dermoid and epidermoid cysts, are known to show reduced water diffusion on DWI. MRI has recently become a valuable adjunct to ultrasonography for fetal gastrointestinal anomalies. Complementary to ultrasonography, prenatal MRI can help further characterize the lesion and can clearly demonstrate the anatomical relationship between the lesion and adjacent organs. We report a case of meconium pseudocyst that was prenatally imaged with ultrasonography and MRI, postnatally complicated by pneumoperitoneum, and proved by postnatal surgery and histopathology. We emphasize the MRI of the pseudocyst, particularly T1-weighted and diffusion-weighted imaging.