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

Abstract

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.

Prenatal Diagnosis of a Segmental Small Bowel Volvulus with Threatened Premature Labor

“…The most common signs are reduced fetal movements and fetal heart rate abnormalities [ 2 – 7 ]. Another symptom frequently described in the literature is the presence of uterine contractions with or without associated threatened premature labor [ 8 , 9 ]. De Felice et al proposed an explanation of relationship between intrauterine midgut volvulus and preterm delivery.…”

“…Prenatal ultrasound signs commonly described in the literature are polyhydramnios, hyperechogenic and dilated bowel loop, typical whirlpool sign, fetal ascites, peritoneal calcifications, and meconium peritonitis with stopped, persistent, or intensive intestinal peristalsis [ 1 – 9 , 11 – 13 ]. In our case, we showed small bowel dilatation with thickened and hyperechogenic intestinal wall and there was a typical whirlpool configuration of the bowel at diagnosis.…”

Meconium Ileus

“…Prenatal ultrasound scan done at 17-18 weeks gestational age may show signs suggestive of meconium ileus; this include enlarged bowel loops or a mass with proximal bowel distention (likely cystic meconium peritonitis) [11,12]. Also, calcified meconium may be seen if meconium peritonitis has already occurred.…”

“…Meconium ileus may be associated with complications such as meconium peritonitis, ileal atresia or stenosis, ileal perforation, and volvulus with or without pseudocyst formation [7][8][9][10][11][12][13]. The infants with cystic fibrosis are more likely to present with complicated meconium ileus [14].…”

Reference curves for the normal fetal small bowel and colon diameters; their usefulness in fetuses with suspected dilated bowel

“…Prenatal diagnosis of these conditions provides an opportunity for parental counseling, close monitoring during pregnancy, and for delivery in a center with a pediatric surgery unit. Some cases may benefit from iatrogenic preterm delivery, for example, intestinal volvulus that may lead to severe bowel necrosis and fetal demise [2]. However, prenatal bowel dilatation can also be transient and even if the dilatation persists until delivery it is possible that no abnormalities are found at postnatal evaluation [3][4][5][6].…”