Fetal echogenic bowel: Is there a national consensus on identification and reporting?

Introduction

Saving Babies' Lives Care Bundle Version 2 highlights the importance of correct identification and reporting of echogenic bowel to improve maternal and newborn outcomes. Yet there is no national consensus to guide sonographers in identifying and reporting fetal echogenic bowel. This two-phase study aims to develop a national consensus to guide sonographers on the identification, classification and reporting of fetal echogenic bowel during the Fetal Anomaly Screening Programme (FASP) second trimester anomaly scan. Phase 1 results are presented capturing the national current practice of sonographers in its identification.

Methods

An online questionnaire survey was deployed to capture numerical and free text data. Data analysis was by descriptive statistics. Participants were recruited via social media and through professional networks and organisations.

Results

A total of 95 participants completed the questionnaire during an 11-week period. Common practice across England included sonographers using a subjective method for identifying fetal echogenic bowel and making comparisons to fetal bone. However, there was wide variance in the fetal bone used and the transducer frequency typically used to assess bowel echogenicity. Confirmation of echogenic bowel was made at the 20-week scan in 58% of cases, 32% following fetal medicine department review with the remaining 10% unsure when confirmation occurred.

Conclusion

While there is common practice in identifying and report echogenic fetal bowel in some areas, there remains disparity within sonographer practice in England's national screening service. This study allowed baseline data to be collated, providing the first steps towards development of guidance for sonographers in identifying and reporting this appearance.

Isolated fetal echogenic bowel in a retrospective cohort: The role of infection screening

OBJECTIVE

Fetal echogenic bowel (FEB) is an ultrasonographic marker of fetal infection. We aimed to determine the utility of infection screening when FEB is isolated.

STUDY DESIGN

Retrospective observational study of isolated FEB cases between 2006-2014. Infection screening included toxoplasmosis, rubella, syphilis, cytomegalovirus (CMV), herpes simplex virus and parvovirus B19. Fetal karyotyping, screening for cystic fibrosis (CF) and follow-up scans were also offered, according to international standards. Incidence of infection and 95% confidence interval (CI) were calculated.

RESULTS

148 patients with 154 fetuses were included. 4.7% of mothers developed acute infection: four patients developed CMV infection (2.7%, 95% CI 1.1-6.9%), in two fetuses infection was confirmed with amniocentesis and pregnancies were terminated; Parvovirus B19 infection was detected in 2 patients (1.4%, 95% CI 0.4-5.0) and confirmed in one fetus, which developed anemia; there was one toxoplasmosis maternal infection (0.7%, 95% CI 0.1-3.8%) treated with spyramicin, whose fetus was not infected. Percentage of chromosomal/genetic abnormalities was 3.2%, CF 1.3%, intra-amniotic bleeding 1.3%, FGR 34% and other ultrasonographic abnormalities at follow-up scans 18%.

CONCLUSIONS

The association between isolated FEB and fetal infection is uncommon (1.9% in our population). CMV maternal infection screening is supported by our findings, whereas screening for other infections needs to be further investigated.

Adverse Perinatal Conditions Associated With Prenatally Detected Fetal Echogenic Bowel in Nova Scotia

OBJECTIVE

This study sought to estimate the association of adverse perinatal outcomes with pregnancies complicated by fetal echogenic bowel.

METHODS

Data for pregnancies complicated with echogenic bowel identified in the second trimester were derived from the tertiary referral IWK Health Centre (Halifax, NS) Viewpoint Ultrasound Database augmented by medical chart review. The study was undertaken between 2003 and 2014. Rates of positive cytomegalovirus and toxoplasmosis infection were determined using maternal serology and amniocentesis results. Rates of intrauterine growth restriction, abnormal karyotype, cystic fibrosis, antenatal bleeding, and bowel abnormalities were also determined. Neonatal information included newborn urine culture results and postnatal genetic testing. Univariate analyses compared rates of infection with isolated echogenic bowel and echogenic bowel with other ultrasound findings, with statistical significance set at P <0.05.

RESULTS

There were 422 pregnancies identified prenatally with echogenic bowel (82% had isolated echogenic bowel). Of these, 92 (22%) had at least one of the foregoing associated abnormalities. Three percent of women had serologic test results positive for cytomegalovirus or toxoplasmosis, with <1% documented newborn infections. Cystic fibrosis and other genetic diagnoses were observed in 8%, intrauterine growth restriction in 14%, antenatal bleeding in 19%, and bowel abnormalities in 3% of the cases of echogenic bowel. Pregnancies with isolated echogenic bowel had an 80% reduction in risk for these significant outcomes, in contrast to a four- to 11-fold increased risk of specific outcomes when additional ultrasound findings were present.

CONCLUSION

An overall rate of adverse conditions of 22% with prenatally detected echogenic bowel serves to inform women and health care providers and emphasizes the importance of careful screening fetal ultrasound studies and timely referral for comprehensive assessment with findings of echogenic bowel for evaluation for associated findings.

Transaldolase Deficiency: A New Case Expands the Phenotypic Spectrum

Transaldolase (TALDO) deficiency has various clinical manifestations including liver dysfunction, hepatosplenomegaly, anemia, thrombocytopenia, and dysmorphic features. We report a case presenting prenatally with hyperechogenic bowel and intrauterine growth restriction. The infant was born small for gestational age, with cutis laxa and hypertrichosis. Postnatally, meconium plug was identified, complicated with intestinal obstruction necessitating laparotomy, partial resection of the intestine, and ileostomy. Liver biopsy revealed cholangiolar proliferation and portal fibrosis. He also suffered from persistent congenital thrombocytopenia requiring platelet transfusions and severe hypothyroidism with normal anatomical and structural gland responding only to the combination of T3 and T4 treatment. Neurologically, severe hypotonia and anisocoria were noted at the age of 2 months. Brain MRI was normal. Shortly after the abdominal surgery, a rapid liver failure ensued, which eventually led to his death. Specific metabolic tests ruled out glycosylation disorders, yet urine analysis using 1H NMR showed accumulation of sedoheptulose which was previously described in patients with transaldolase deficiency. Sequencing of the gene-encoding transaldolase (TALDO1) revealed a homozygous stop mutation c.669C>G; p.Tyr223*. In conclusion, we present an infant with a novel homozygous mutation in TALDO1, causing TALDO deficiency, and extend the clinical characteristics of this rare syndrome.

Prenatal diagnosis of enterolithiasis at 18 weeks: multiple foci of intraluminal calcified meconium within echogenic bowel

Enterolithiasis is an uncommon finding of a dilated hyperechogenic bowel with multiple ball-like echogenic structures at a routine prenatal check-up using ultrasonography. We here report a case of prenatally diagnosed enterolithiasis at 18 weeks of gestation, showing multiple hyperechogenic foci rolling within the bowel fluid after peristalsis. The size of the dilated bowel gradually increased during pregnancy. Magnetic resonance image demonstrated the dilated lower bowel with blind-ending rectum. A postnatal contrast medium study with retrograde urethrography revealed a middle imperforate anus and a rectourethral fistula. A careful examination, even before 20 weeks of gestation, is extremely useful in demonstrating intraluminal coarse calcifications within an echogenic bowel.