Intrauterine intussusception presenting as fetal ascites at prenatal ultrasonography

Intrauterine intussusception, an uncommon cause of bowel obstruction, has rarely been detected by prenatal ultrasonography. We report two cases of intrauterine intussusception after gestation, which presented as isolated fetal ascites at 30 weeks of gestation by ultrasonography. In case 1, on the follow-up ultrasonography at 32 weeks of gestation, the previously observed ascites had disappeared, whereas the echogenicity of the bowel was increased without any sign of dilation, suggesting the presence of meconium peritonitis. The fetus was delivered at 39 weeks. In case 2, however, the amount of fetal ascites became increased, and the fetus was delivered at 34 weeks of gestation. After delivery, both infants were surgically explored with resection of the ileum with end-to-end anastomosis because of intrauterine intussusception and ileal atresia. From the experience of these cases, we suggest that the ultrasonographic finding of isolated or transient fetal ascites might contribute to the early diagnosis and management of intrauterine intussusception.     

Isolated fetal ascites caused by bowel perforation due to colonic atresia

An isolated fetal ascites is a rare ultrasonographic finding. It is commonly diagnosed in association with fetal genitourinary or gastrointestinal conditions, mainly bowel obstruction. We present the sonographic features and neonatal outcome of a fetus with a large bowel obstruction, perforation and subsequent development of meconium peritonitis, prenatally diagnosed as isolated fetal ascites. A colonic atresia should be also included in the differential diagnosis of isolated fetal ascites.     

Isolated fetal ascites caused by bowel perforation due to colonic atresia.

An isolated fetal ascites is a rare ultrasonographic finding. It is commonly diagnosed in association with fetal genitourinary or gastrointestinal conditions, mainly bowel obstruction. We present the sonographic features and neonatal outcome of a fetus with a large bowel obstruction, perforation and subsequent development of meconium peritonitis, prenatally diagnosed as isolated fetal ascites. A colonic atresia should be also included in the differential diagnosis of isolated fetal ascites.     

Correlation of prenatal ultrasound and postnatal outcome in meconium peritonitis

OBJECTIVES: To study the relationship between prenatal ultrasound features and postnatal course of meconium peritonitis. METHODS: Meconium peritonitis was diagnosed by prenatal ultrasound. Fetuses were treated by intrauterine paracentesis of ascites when indicated, and symptomatic newborns received surgery. RESULTS: Totally 17 cases were enrolled. Prenatal ultrasound findings include abdominal calcification (16/17), fetal ascites (12/17), hydramnios (9/17), pseudocyst (7/17) and dilated bowel loop (6/17). Persistent ascites, pseudocyst or dilated bowel loop are most sensitive (92%) to predict postnatal surgery (p = 0.022). The survivors have a higher gestational age at birth (36.4 vs. 33.3 weeks, p = 0.008). Persistent ascites and postnatal persistent pulmonary hypertension of the newborns significantly correlate with neonatal mortality (p = 0.029 and 0.022). CONCLUSION: Prenatal ultrasound can predict the neonatal outcome in meconium peritonitis.     

Management of meconium peritonitis: a remarkable case of idiopathic meconium peritonitis diagnosed antenatally

Meconium peritonitis is an inflammatory peritonitis induced by meconium extruding into the peritoneal cavity through a perforation of the fetal intestine. Antenatal diagnosis is possible. Prognosis depends on the pathology having caused perforation. This is often unknown. The objectives of this article are to analyze the contribution of antenatal investigations to estimating neonatal prognosis of meconium peritonitis, and to define optimal management. We describe a case of meconium peritonitis diagnosed in utero with particularly severe ultrasound presentation suggesting a potentially lethal course for the neonate. An eutrophic infant was delivered vaginally after preliminary aspiration of the meconium ascites. The neonate presented with a very distended abdomen and responded well to neonatal resuscitation. Laparotomy exploration confirmed the diagnosis of meconium peritonitis. No cause was identified. No obvious perforation was found. The postsurgery period was uneventful. At later follow-up the infant was doing well, free of further problems notably of any digestive disorder. Antenatal ultrasound features suggestive of severe meconium peritonitis are distended fetal bowel loops, huge cystic masses, major meconium ascites, and polyhydramnios. These neonates have a high risk of obstruction and intestinal perforation. Intestinal resection is frequently required. Cardiopulmonary resuscitation is necessary more often in these neonates with a higher risk of fatal outcome due to respiratory distress syndrome or surgery complications. Prognosis remains good after antenatal diagnosis for neonates free of cystic fibrosis, providing delivery takes place in a center with adequate technical facilities.     

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.     

Meconium peritonitis: extrusion of meconium and different sonographical appearances in relation to the stage of the disease.

By chance, we had the opportunity to make serial sonographic observations of the extrusion of meconium in a case of meconium peritonitis. Inflammation leads to exudative processes and production of fluid (ascites) in the fetal abdomen. Sonography at that stage of the disease may lead to a misdiagnosis such as 'fetal ascites' or 'non-immune hydrops'. After bowel perforation and extrusion of meconium, the latter appears as a solitary mass inside fetal ascites or as disseminated echogenic masses distributed subdiaphragmatically or perihepatically. Within a couple of days, in most cases the echogenicity of the masses increases. Calcifications lead to distinct shadowing. These calcifications are often the only visible signs of a previous meconium peritonitis. Serial sonograms are essential for the management of pregnancies with meconium peritonitis. If the amount of fetal ascites does not increase and no signs of cardiovascular stagnation appear, no invasive intrauterine diagnostic and therapeutic steps are required. In none out of the nine cases was a cause found.     

Prenatal diagnosis of meconium peritonitis in a twin pregnancy after intracytoplasmic sperm injection. A case report

BACKGROUND: Meconium peritonitis occurring in pregnancies following artificial reproductive techniques (ART) is rare. We report the first case of meconium peritonitis following intracytoplasmic sperm injection (ICSI). CASE: A 37-year-old woman attended our in vitro fertilization (IVF) program because her husband suffered from hypospermatogenetic azoospermia due to cancer surgery and radiotherapy. The patient achieved a twin pregnancy through ICSI from testicular sperm extraction at our IVF center. Meconium peritonitis, fetal ascites, polyhydramnios, bowel dilatation, hydrocele and intraabdominal calcification were noted in one of the twins on ultrasound at 30 weeks' gestation. Cesarean section due to breech presentation in labor was performed at 36 weeks' gestation. A normal female and male infant with a distended abdomen were delivered. Emergency laparotomy was performed on the male twin because of dyspnea. A 0.2-cm perforation was found in the terminal ileum. Ileotomy was performed and closed after 27 days. CONCLUSION: Prenatal diagnosis of meconium peritonitis is possible through careful ultrasonographic examination, and early surgical intervention and intensive postoperative support are required to improve the prognosis.     

Prenatal Ultrasound Diagnosis of Small-Bowel Torsion

Background: We report a case of congenital small-bowel torsion detected by prenatal ultrasonographic examination.Case: A 27-year-old primigravida was found to have a fetus with a small-bowel obstruction by ultrasound examination during the third trimester. At 35 weeks of gestation, she complained of absence of fetal activity. A nonstress test showed a nonreactive pattern with reduced baseline variability. Sonographic examination revealed heterogeneous echogenicity within the dilated bowel, and loss of peristalsis. Also noted was a small amount of fetal ascites. After birth, torsion of the dilated small bowel associated with ileal atresia was found at exploratory laparotomy.Conclusion: Serial sonographic examinations with special attention to changes in the dilated bowel are useful in the management of prenatally diagnosed small-bowel obstruction.     

Fetal meconium pseudocyst secondary to in utero perforation of colon transversum and meconium peritonitis

Fetal bowel intrauterine perforation causes sterile inflammation of the peritoneum, known as meconium peritonitis. In some cases the perforation closes spontaneously, thus forming a meconium pseudocyst between the intestinal loops and the omentum. Meconium peritonitis, complicated by pseudocyst formation, should always be considered when a fetal abdominal mass with diverse echogenicity and hyperechogenic calcifications is observed on prenatal ultrasound. Usually, this is associated with ascites and/or polyhydramnios. The differential diagnosis necessitates exclusion of all other fetal abdominal tumors. We present a case report of meconium pseudocyst diagnosed prenatally at 32 weeks of gestation which was successfully treated by surgery after birth.     

Repeated paracentesis in a fetus with meconium peritonitis with massive ascites: a case report

Meconium peritonitis (MP) is defined as a sterile inflammatory reaction in the fetal abdomen that is seen in cases of intrauterine bowel perforation. Recently, there have been increasing numbers of fetuses with MP prenatally diagnosed by ultrasonography. Massive fetal ascites in MP may cause hydrops and hypoplastic lungs. However, antepartum management of MP has not yet been established. We encountered a fetus with MP and massive ascites. Repeated paracentesis between 29 weeks and 4 days and 31 weeks and 6 days of gestation prevented the progression to fetal hydrops and hypoplastic lungs, which may occur due to massive meconium ascites with an increased preload index. Amniocentesis was also performed in patients with polyhydramnios for treatment of preterm labor. These observations suggest that aggressive therapy can prolong the gestation period and improve MP treatment outcomes.     

Peritonitis meconial

Objective

To gain greater insight into a little known entity.

Material and methods

Prompted by a case of meconium peritonitis prenatally diagnosed in our ultrasound unit, we performed a literature search including most of the cases reported from January 1988 to August 2005.

Results

The most frequent ultrasonographic findings include intraabdominal calcifications (71.8%), fetal ascites (49%), meconium pseudocyst (47%), dilated bowel loops (31.2%), and polyhydramnios (34.4%). Perinatal prognosis is directly connected with the underlying cause, the most frequent being ileal obstruction. However, in 50% of cases, the cause of the perforation is not located. Cystic fibrosis is present in less than 10%. The mean perinatal mortality is 13%.

Conclusions

The reported casuistics are scarce and there are discrepancies in the diagnostic criteria, underlying disease, and prenatal diagnosis. Meconium peritonitis cannot be managed by extrapolating postnatal data to prenatal findings. This entity continues to be «unknown» in prenatal diagnosis.     

Intussusception in a preterm neonate; a very rare, major intestinal problem--systematic review of cases

Intussusception is an extremely rare disorder in preterm infants and it is often misdiagnosed as necrotizing enterocolitis. We report a case of intussusception in a 30-day-old preterm infant of 26 weeks of gestational age and a birthweight of 610 g who was diagnosed via abdominal ultra sonography. A systematic review of the literature was performed and reports on 23 previous cases were found. The presence of recognizable causes of intussusception in preterms, such as Meckel's diverticulum, bowel polypus, etc. was very infrequent. Comorbidity before and after intussusception is heterogeneous and related to prematurity. The intussusception is predominantly located in the small bowel (91.6%)--ileal or jejunal. The condition is misdiagnosed as NEC and managed conservatively until clinical deterioration occurs. A definitive diagnosis is thus established during abdominal surgery, which is usually delayed an average of 9.5 days from the onset of symptoms. Our case illustrates the capability of abdominal ultrasonography to establish early diagnosis of intussusception in the premature newborn.     

Prenatal diagnosis and management of an intestinal volvulus with meconium ileus and peritonitis

Fetal intestinal volvulus is a rare but serious finding with a high risk of potential life threatening fetal complications. Delay in diagnosis or treatment can increase mortality and morbidity. We report a case of mild fetal bowel dilatation at 30 weeks of gestation and intestinal volvulus presented by the ‘whirl-sign’, intestinal perforation and meconium peritonitis with fetal ascites and polyhydramnios at 33 weeks of gestation. This case emphasizes the role of examination of the bowel in third trimester ultrasound and the importance of quick decision to delivery and interdisciplinary perinatal management at suspected fetal volvulus with bowel necrosis and intraabdominal bleeding.     

Fetal meconium peritonitis in single and twin pregnancy. Two cases report

We present two cases of fetal meconium peritonitis in a single and twin pregnancy, respectively. The first case diagnosis was made at 30 weeks and was confirmed after delivery of the twins by cesarean section at 37 weeks. The second case diagnosis was made at 31 week and was confirmed at 37 weeks. Meconium peritonitis is a rare prenatal complication that results from intrauterine perforation of small bowel with spillage of sterile meconium into peritoneal cavity. We now report two cases of meconium peritonitis diagnosed at 30 and 31 weeks gestation. Received: 20 March 2001 / Accepted: 13 June 2001     

Meckel’s diverticulum complicating pregnancy

INTRODUCTION: Symptomatic Meckel's diverticulum is a rare entity in pregnancy. The clinical presentation is variable and preoperative diagnosis is hampered by the various anatomical and physiological changes of pregnancy that can obscure serious underlying intra-abdominal pathology. CASE REPORT: We report a 14-year-old who presented at 32 weeks' gestation with worsening abdominal pain, distension, and leukocytosis. Abdominal computed tomography showed a pelvic fluid collection with extraluminal air suggestive of a perforated viscus and mechanical small bowel obstruction with features of a closed-loop obstruction. Explorative laparotomy revealed a perforated Meckel's diverticulum. Multiple adhesions between the appendix and the perforated diverticulum, and phlegmon sequelae led to the incarceration of an adjacent segment of ileum. DISCUSSION: Meckel's diverticulum in pregnancy can have serious consequences. There is a high rate of perforation due to delayed diagnosis and surgical intervention. Our report and review of the literature suggest that a high index of clinical suspicion can lead to earlier diagnosis and help to keep maternal and fetal morbidity and mortality to a minimum.     

Obstetrical and neonatological aspects of a child with atresia of the small bowel

A patient was admitted to the hospital in the 31st week of gestation because of reduced sensation of fetal movements and a pathologic fetal heart rate tracing (Fig. 1). At first no underlying pathology could be found. After a week she developed a polyhydramnios. After repeated ultrasonographic examinations an atresia of the fetal small bowel was suspected (Fig. 2). The diagnosis could be confirmed after birth and on the same day the child was operated on. An atresia of the ileum was found. After liberal resection of the atretic part, recovery was complete. The malformation has an incidence of 1: 12,500-20,000. The etiology is thought to be a temporary or definite obstruction of a mesenterial artery branch, supplying the small bowel of the fetus. It develops after organogenesis and could be caused by kinking of an artery during rotation, an embolus, amniocentesis, volvulus, intussusception or snaring at the umbilical ring. Polyhydramnios is the first symptom in about one third of the cases. Diagnosis can be confirmed by fetography or ultrasonography. The latter is preferred because of its non-invasivity. In amniotic fluid, high levels of bile salts (up to thirty times the normal level) have been described in combination with atresia of the small bowel. A diminished disacharidase activity is also ascribed to it. Most of the time the diagnosis is suspected after birth on the basis symptoms such as a gastric aspirate of more than 25 cc, bile vomiting within a few hours, absence of meconium stool or distension of the abdomen. It can be confirmed by X-ray examination.(ABSTRACT TRUNCATED AT 250 WORDS)     

小儿异位胃黏膜合并急腹症55例临床分析

目的探讨小儿异位胃黏膜症合并急腹症的临床特点。 方法回顾分析了2000 12—2005 12中国医科大学第二临床学院收治的55例经病理证实存在异位胃黏膜的急腹症患儿，对其临床资料进行分类汇总和分析。 结果男44例，女11例；年龄3个月至13岁，平均45岁。临床诊断下消化道出血31例，急性肠套叠13例，急性肠梗阻5例，急性腹膜炎6例；手术切除肠管标本经病理检查证实均有异位胃黏膜。其中Meckel憩室40例，肠重复畸形11例，肠壁正常4例。 结论异位胃黏膜可能是小儿急腹症的病因之一；急腹症患儿ECT检查阴性也应开腹探查，以免遗漏异位胃黏膜。     

Prenatal ultrasonic diagnosis of multiple bowel atresias

This case illustrates the course of an obstructive process through spontaneous perforation resulting in decompression of dilated bowel loops. The resulting meconium peritonitis appeared as fetal ascites. Postnatal investigations and laparotomy confirmed the diagnosis of a rare form of multiple congenital atresias of the bowel.     

Cholestasis of Pregnancy and Intrauterine Intestinal Obstruction

A woman is described with cholestasis of pregnancy who gave birth to three successive infants with evidence of intrauterine bowel obstruction and meconium peritonitis.