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Antenatal diagnosis of congenital gastro-intestinal obstruction by ultrasonography. A case report
ht. J. GynaecoL Obstet., 1981, 19: 141-143 0 International Federation of Gynaecology & Obstetrics
ANTENATAL DIAGNOSIS OF CONGENITAL ULTRASONOGRAPHY. A CASE REPORT
GASTRO-INTESTINAL
OBSTRUCTION BY
A.A. OPANEYE Department of Obstetricsand Gynaecology, Stepping Hill Hospital, Stockport, Cheshire SK2 7JE, UK (Received July 23rd, 1980) (Accepted November 25th, 1980)
Abstract AA (Dept of Obstetrics and GynaeStepping Hill Hospital, Stockport, Cheshire SK2 7JE, UK). Antenatal diagnosis of congenital gastro-in testinal obstruction by ultrasonograph y. Int J Gynaecol Obstet 19: 141-143, 1981 A case of antenatal diagnosis of congenital duodenal atresia by ultrasonic scan in a multigravida with pre-eclampsia and polyhydramnios is presented. Opaneye
cology.
Key
words:
Ultrasonic scan nios
Congenital duodenal atresia Preeclampsia Polyhydram-
Case history .
Mrs B.L. was an 18-year-old woman gravida 2 para 1. Her first pregnancy ended prematurely at 34 weeks with a spontaneous delivery of a male infant weighing 1800 g. She was first seen at 20 weeks by dates during her present pregnancy. On that occasion, she was normotensive (1 lo/60 mmHg), her urine analysis was normal and fundal height corresponded with her dates. Her pregnancy was uneventful until 32 weeks when she developed moderate pre-eclampsia with a blood pressure of 160/l 10 mmHg. The abdomen was tense, uterine size corresponded with 34 weeks’ gestation and polyhydramnios was present. Fetal heart was heard with the aid of a sonicaid. She was sedated with 10 mg intramus-
cular diazepam and was placed on complete bed rest. There was an initial improvement in her condition. She had good. diuresis and became normotensive. Biochemical placental function tests, plasma HPL and oestriols were normal. An ultrasonic scan performed at 34 weeks showed a biparietal diameter of 89.7 mm. The fetal spine was normal. The presence of polyhydramnios was noted and in addition, a “double-cystic” shadow suggestive of gastrointestinal obstruction was seen (Fig. 1). Radiological examination at 35 weeks showed no fetal skeletal abnormality. At 35 . weeks, the patient’s condition deteriorated . rapidly. Her blood pressure rose to 1SO/ 110 mmHg, she had proteinuria of 0.11 g/l and there was a fall in her plasma oestriol level. Because of this deterioration, labor was surgically induced. At amniotomy, 4000 ml of clear liquor was obtained. Labor progressed rapidly to full dilatation of the cervix in 3 h, and she had a normal delivery of a 2300 g male infant with the aid of an episiotomy . The baby was in good condition at birth and no resuscitation was required. At the age of 4 h, vomiting began. This continued intermittently and later became bile stained. A plain abdominal X-ray (Fig. 2) revealed gas in the stomach; the other parts of the intestines were devoid of air, confirming duodenal atresia. The baby was transferred to a Neonatal Surgical Unit. Laparotomy was performed on the same day at which time a duodeno-duodenostomy was performed to relieve the obstruction due to duodenal Int J Gynaecol Obstet 19
14 2 Opaneye
Fig. 1.
Ultrasonic scan at 34 weeks pregnancy showing a “double-cystic”
atresia. A gastrotomy was also done at the same time. Post-operatively the baby developed hyperbilirubinaemia which required an exchange transfusion and phototherapy. The total serum bilirubin gradually decreased. He was given a course of penicillin and gentamycin following a blood culture which grew a coagulase negative staphylococcus. Although he had an initial feeding difficulty, he made a good recovery and was discharged home. At the age of 1 year, he is thriving well apart from occasional respiratory tract infection. Int J Gynaecol Obstet 19
shadow in the fetal abdomen in the transverse section.
Discussion The aetiology of polyhydramnios is unknown. About 50% of pregnancies complicated by polyhydramnios are associated with either maternal pathology like diabetes mellitus or congenital fetal abnormalities, especially those of the central nervous system. Other conditions include monozygotic twins and congenital atresia of the fetal gastrointestinal tract proximal to the ligament of Treitz. Biochemical and biophysical methods are increasingly used to determine fetal well-
Antenatal diagnosis of congenital gastro-intestinal obstruction
by ultrasonography
143
ness of ultrasound as an obstetrician’s tool in pre-natal “physical” examination of the fetus. Having excluded multiple pregnancy, and cephalic and spinal abnormalities, the fetal abdomen should be carefully examined by ultrasound in cases of polyhydramnios. With the patient’s well-informed consent, it is prudent to perform amniocentesis and, although difficult, carry out fetal cell culture for chromosome studies as soon as possible. Depending on the result, consequent management of the pregnancy should be on the mutual agreement between the patient and the obstetrician. Emergency cesarea.n section for the delivery of a child with Down’s syndrome may thus be averted. Prenatal diagnosis may also make unnecessary the decision regarding repair of congenital duodenal atresia in the Down’s infant. Acknowledgements I am grateful to Dr. William Kelso for permission to publish this case, and to Helen and Lynn in the Scan Department. X-ray of chest and abdomen showing gas in the stomach only.
Fig. 2.
being. Assays of substances like ol-feto protein help in the detection of some malformations of the central nervous system, while radiography may detect gross skeletal abnormalities. Some congenital abnormalities of soft tissues may be detected prenatally by careful ultrasonic examination of the fetus. In some earlier reports [ 1,2], polyhydramnios and duodenal atresia were associated with Down’s Syndrome (Trisomy 21), but this association was absent in the present case. This case illustrates the continued useful-
References Duenhoelter JH, Santos-Ramos, Rosenfeld R, Coln CD: Prenatal diagnosis of gastro-intestinal tract obstruction. Obstet Gynaecol47: 618, 1976. Gee H, Abdulla U: Antenatal diagnosis of fetal duodenal atresia by Ultrasonic Scan. Br Med J 2: 1265, 1978. Loveday BJ, Barr BA, Aitken J: Antenatal diagnosis of duodenal atresia. Br J Radio1 48: 103 1, 1975. Moya F, Apgar V, James LS et al.: Hydramnios and congenital anomalies. J.A.M.A. 173: 1552, 1960. Address for reprints: A.A. Opaneye General Hospital South Shields Tyne and Wear NE34 OPL UK
Int J Gynaecol Obstet 19
ANTENATAL DIAGNOSIS OF CONGENITAL ULTRASONOGRAPHY. A CASE REPORT
GASTRO-INTESTINAL
OBSTRUCTION BY
A.A. OPANEYE Department of Obstetricsand Gynaecology, Stepping Hill Hospital, Stockport, Cheshire SK2 7JE, UK (Received July 23rd, 1980) (Accepted November 25th, 1980)
Abstract AA (Dept of Obstetrics and GynaeStepping Hill Hospital, Stockport, Cheshire SK2 7JE, UK). Antenatal diagnosis of congenital gastro-in testinal obstruction by ultrasonograph y. Int J Gynaecol Obstet 19: 141-143, 1981 A case of antenatal diagnosis of congenital duodenal atresia by ultrasonic scan in a multigravida with pre-eclampsia and polyhydramnios is presented. Opaneye
cology.
Key
words:
Ultrasonic scan nios
Congenital duodenal atresia Preeclampsia Polyhydram-
Case history .
Mrs B.L. was an 18-year-old woman gravida 2 para 1. Her first pregnancy ended prematurely at 34 weeks with a spontaneous delivery of a male infant weighing 1800 g. She was first seen at 20 weeks by dates during her present pregnancy. On that occasion, she was normotensive (1 lo/60 mmHg), her urine analysis was normal and fundal height corresponded with her dates. Her pregnancy was uneventful until 32 weeks when she developed moderate pre-eclampsia with a blood pressure of 160/l 10 mmHg. The abdomen was tense, uterine size corresponded with 34 weeks’ gestation and polyhydramnios was present. Fetal heart was heard with the aid of a sonicaid. She was sedated with 10 mg intramus-
cular diazepam and was placed on complete bed rest. There was an initial improvement in her condition. She had good. diuresis and became normotensive. Biochemical placental function tests, plasma HPL and oestriols were normal. An ultrasonic scan performed at 34 weeks showed a biparietal diameter of 89.7 mm. The fetal spine was normal. The presence of polyhydramnios was noted and in addition, a “double-cystic” shadow suggestive of gastrointestinal obstruction was seen (Fig. 1). Radiological examination at 35 weeks showed no fetal skeletal abnormality. At 35 . weeks, the patient’s condition deteriorated . rapidly. Her blood pressure rose to 1SO/ 110 mmHg, she had proteinuria of 0.11 g/l and there was a fall in her plasma oestriol level. Because of this deterioration, labor was surgically induced. At amniotomy, 4000 ml of clear liquor was obtained. Labor progressed rapidly to full dilatation of the cervix in 3 h, and she had a normal delivery of a 2300 g male infant with the aid of an episiotomy . The baby was in good condition at birth and no resuscitation was required. At the age of 4 h, vomiting began. This continued intermittently and later became bile stained. A plain abdominal X-ray (Fig. 2) revealed gas in the stomach; the other parts of the intestines were devoid of air, confirming duodenal atresia. The baby was transferred to a Neonatal Surgical Unit. Laparotomy was performed on the same day at which time a duodeno-duodenostomy was performed to relieve the obstruction due to duodenal Int J Gynaecol Obstet 19
14 2 Opaneye
Fig. 1.
Ultrasonic scan at 34 weeks pregnancy showing a “double-cystic”
atresia. A gastrotomy was also done at the same time. Post-operatively the baby developed hyperbilirubinaemia which required an exchange transfusion and phototherapy. The total serum bilirubin gradually decreased. He was given a course of penicillin and gentamycin following a blood culture which grew a coagulase negative staphylococcus. Although he had an initial feeding difficulty, he made a good recovery and was discharged home. At the age of 1 year, he is thriving well apart from occasional respiratory tract infection. Int J Gynaecol Obstet 19
shadow in the fetal abdomen in the transverse section.
Discussion The aetiology of polyhydramnios is unknown. About 50% of pregnancies complicated by polyhydramnios are associated with either maternal pathology like diabetes mellitus or congenital fetal abnormalities, especially those of the central nervous system. Other conditions include monozygotic twins and congenital atresia of the fetal gastrointestinal tract proximal to the ligament of Treitz. Biochemical and biophysical methods are increasingly used to determine fetal well-
Antenatal diagnosis of congenital gastro-intestinal obstruction
by ultrasonography
143
ness of ultrasound as an obstetrician’s tool in pre-natal “physical” examination of the fetus. Having excluded multiple pregnancy, and cephalic and spinal abnormalities, the fetal abdomen should be carefully examined by ultrasound in cases of polyhydramnios. With the patient’s well-informed consent, it is prudent to perform amniocentesis and, although difficult, carry out fetal cell culture for chromosome studies as soon as possible. Depending on the result, consequent management of the pregnancy should be on the mutual agreement between the patient and the obstetrician. Emergency cesarea.n section for the delivery of a child with Down’s syndrome may thus be averted. Prenatal diagnosis may also make unnecessary the decision regarding repair of congenital duodenal atresia in the Down’s infant. Acknowledgements I am grateful to Dr. William Kelso for permission to publish this case, and to Helen and Lynn in the Scan Department. X-ray of chest and abdomen showing gas in the stomach only.
Fig. 2.
being. Assays of substances like ol-feto protein help in the detection of some malformations of the central nervous system, while radiography may detect gross skeletal abnormalities. Some congenital abnormalities of soft tissues may be detected prenatally by careful ultrasonic examination of the fetus. In some earlier reports [ 1,2], polyhydramnios and duodenal atresia were associated with Down’s Syndrome (Trisomy 21), but this association was absent in the present case. This case illustrates the continued useful-
References Duenhoelter JH, Santos-Ramos, Rosenfeld R, Coln CD: Prenatal diagnosis of gastro-intestinal tract obstruction. Obstet Gynaecol47: 618, 1976. Gee H, Abdulla U: Antenatal diagnosis of fetal duodenal atresia by Ultrasonic Scan. Br Med J 2: 1265, 1978. Loveday BJ, Barr BA, Aitken J: Antenatal diagnosis of duodenal atresia. Br J Radio1 48: 103 1, 1975. Moya F, Apgar V, James LS et al.: Hydramnios and congenital anomalies. J.A.M.A. 173: 1552, 1960. Address for reprints: A.A. Opaneye General Hospital South Shields Tyne and Wear NE34 OPL UK
Int J Gynaecol Obstet 19