Ultrasonographic detection of intrauterine intussusception resulting in ileal atresia complicated by meconium peritonitis

A Rare Case of Jejunal Atresia Due to Intrauterine Intussusception

Intestinal atresia is generally caused by intrauterine vascular obstructions involving mesenteric vessels. Intrauterine intussusceptions (IUI) are one of these disruptive events. Intestinal intussusceptions affects children commonly between 3 months and 3 years of age, but it rarely affects in intrauterine life. The relationship between intrauterine intussusception and intestinal atresia has been demonstrated by few cases in literature, suggesting intrauterine intussusception as a rare cause of intestinal atresia. We report a 7-day-old full term neonate presenting with intrauterine intussusceptions (jejuno-jejunal) resulting in jejunal atresia.

Intrauterine intussusception: a rare cause of intestinal atresia

Intrauterine intussusception is an uncommon cause of intestinal atresia. We report a case of ileal atresia owing to antenatal intussusception revealed as an intraluminal polypoid lesion after surgical intervention.

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.

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.

Fetal meconium peritonitis complicated with bacterial infection

Fetal meconium peritonitis complicated by bacterial infection is extremely rare. We report a case of fetal ascites at 21 weeks of gestation with subsequent development of loculation, encapsulation, and calcification at 25 weeks. Paracentesis of loculated ascitic fluid at 28 weeks of gestation showed a purulent appearance with the presence of cocci bacteria, increase in white cell count, and a low glucose level, which were suggestive of bacterial infection. However, no sources of maternal infection could be identified. The total bilirubin level of the ascitic fluid was normal (21 micromol/L). A healthy baby was delivered at 37 weeks. CT scan revealed normal bowel without any sign of perforation. We postulate that when ascitic fluid becomes loculated, a normal bilirubin level on paracentesis indicates spontaneous closure of a previous bowel perforation.

Fetal intra-abdominal calcifications from meconium peritonitis: sonographic predictors of postnatal surgery

OBJECTIVE

To study the relationship between prenatal ultrasound features and postnatal course of meconium peritonitis.

STUDY DESIGN

We reviewed our cohort of cases of meconium peritonitis (MP) (n = 13/37, 225 pregnancies or 0.3/1000) as well as those published in the English literature with prenatal ultrasonographic findings and postnatal follow-up (n = 56). The total number of cases (n = 69) was divided into 4 grades of progressive severity based on the number of pertinent sonographic findings: grade 0, isolated intra-abdominal calcifications (n = 18); grade 1, intra-abdominal calcifications and ascites (n = 17) or pseudocyst (n = 2) or bowel dilatation (n = 6); grade 2, two associated findings (n = 20); and grade 3, all sonographic features (n = 6). Presence of polyhydramnios was also recorded. Prenatal predictors of need for neonatal surgery and risk of neonatal death were identified using Chi-square and Fisher exact test, with P < 0.05 considered significant.

RESULTS

Neonatal surgical intervention was required in 0% (0/18) of newborns with grade 0 MP; in 52% (13/25) of those with grade 1; in 80% (16/20) with grade 2; and in 100% (6/6) with grade 3 MP (P < 0.001, Chi-square for trend). Moreover, neonatal surgery was more frequent in the presence than absence of polyhydramnios [69% (18/26) vs 37% (16/43); P = 0.007]. Neonatal mortality was 6% (4/69; 3 after surgery and 1 for premature delivery) and it was confined to the subgroup with polyhydramnios (4/26, 15%).

CONCLUSIONS

Prenatal sonographic features are related to postnatal outcome. Persistently isolated intra-abdominal calcifications have an excellent outcome. Delivery in a tertiary care center is recommended when calcifications are associated with other sonographic findings.

Meckel's Diverticulum Induced Intrauterine Intussusception Associated with Ileal Atresia Complicated by Meconium Peritonitis

Intrauterine intussusception with a leading point of Meckel's diverticulum is a rare cause of ileal atresia, which may cause bowel obstruction and perforation. We report such a case complicated by meconium peritonitis. The fetal ultrasonogram revealed ascites, dilated bowel loops and intra-abdominal calcification at a gestational age of 30 weeks. The patient was delivered at 37 weeks and laparotomy was performed to manage the intestinal obstruction. The operative findings showed that Meckel's diverticulum had induced intussusception associated with the ileal atresia with meconium peritonitis. The ileum was resected with end-to-end anastomosis. The postoperative course was uneventful. In this patient, ascites and intraperitoneal calcification were caused by ileal atresia, which may have been induced by intrauterine intussusception.

Meconium peritonitis: prenatal diagnosis, postnatal management and outcome

OBJECTIVES

Prenatal ultrasonography (USS) is a routine screening test for fetal abnormalities. Its accuracy for detecting meconium peritonitis (MP), which may carry high mortality, is important for prenatal counseling. The aim of this study was to assess the accuracy of prenatal USS for diagnosing MP and predicting patient outcomes.

METHODS

The prenatal and postnatal medical records of all patients referred to our institutions with confirmed MP were reviewed, with emphasis on prenatal USS findings, results of postnatal investigations, operative findings, outcomes, and possible causes of MP.

RESULTS

From January 2000 to November 2004, seven fetuses were confirmed to have MP at birth. Three MP patients (3/7, 43%) were diagnosed prenatally because of USS showing ascites and calcification/dilated or hyperechoic bowel loops. One (1/7, 14.3%) suspected cystic MP was confirmed by prenatal MRI. In the other three cases, USS showed only ascites. All patients had postnatal contrast CT scans. Two patients' CT scans showed persistent intestinal perforation not visible with prenatal USS, and required emergency operations. All patients survived and prospered, and were sweat test negative.

CONCLUSIONS

Prenatal USS allows suspected MP babies to be transferred to a tertiary centre for delivery and appropriate management. In this way, the chances of survival of these babies can be excellent if they are not associated with cystic fibrosis (CF). Prenatal MRI can improve the low diagnostic yield of prenatal USS for MP. Postnatal contrast CT scan is required to define persistent intestinal perforation invisible with prenatal USS.

Meconium peritonitis and pseudo-cyst formation: prenatal diagnosis and post-natal course

OBJECTIVES

Intra-uterine bowel perforation can occur secondary to a variety of abnormalities and cause sterile peritonitis in the fetus (generalised = type I). If sealing of the perforation does not take place, a thick-walled pseudo-cyst can form (type II).

METHODS

Over a 12-year period, 21 616 pregnancies were screened for gastro-intestinal malformations using prenatal ultrasound. We identified 1077 cases suspicious of surgically correctable malformations. Post-natal diagnoses and outcome were worked up retrospectively.

RESULT

We found 96 fetuses with suspected gastro-intestinal malformations. Prenatal bowel perforation with meconium peritonitis was confirmed in 11 cases. In 5 of these 11, the correct diagnosis had been predicted prenatally. One child presented as a fetal and neonatal emergency (case report). Ten of the eleven infants were operated on during their first day of life. Intra-operative findings were atresia (n = 4), meconium ileus (n = 6) and no obvious cause (n = 1). Two children suffered fatal complications.

CONCLUSION

Meconium peritonitis and meconium pseudo-cysts as its special manifestation are assessable by prenatal diagnosis but present in different ways. They can present as fetal ascites or echogenic bowel and cause fetal or neonatal distress, requiring close observation and highly specialised care.

[Intrauterine intussusception causing intestinal atresia during pregnancy]

CASE REPORT

A case of intrauterine intussusception causing ileal atresia is reported. The neonate presented at the age of one day with bilious vomiting, failure to pass meconium and progressive abdominal distension. A clinical diagnosis of intestinal obstruction was made, and was confirmed by plain abdominal radiographs. At laparotomy, atresia of the terminal ileum was found. The lumen of the resected distal segment contained an intussusceptum. The blind ends were resected and an anastomosis was performed. Recovery was uneventful.

COMMENTS

Intrauterine bowel intussusception is a rare clinical entity. When intussusception occurs in the foetus and the time elapsed is enough to allow for gangrene and resorption of the intussuscepted portions of the bowel, intestinal atresia may result.

CONCLUSIONS

The careful examination of the distal blind end of the ileum aids to obtain a correct classification and etiologic diagnosis of the atresia.

Intestinal atresia presenting as bilateral scrotal pneumatocele: A case report

The authors report on a newborn baby with congenital hydrocele in whom pneumoscrotum developed. Air and meconium were found over the hernia sac, owing to ileal atresia with perforation. Gas in the scrotum usually is inside herniated bowel, but it can be the first sign of pneumoperitoneum.