- Email: [email protected]
Meconium peritonitis with ascites resulting in dystocia
MECONIUM PERITONITIS WITH ASCITES RESULTING IN DYSTOCIA LEONARD
A.
WALL,
M.D.,
KANSAS CITv,
Mo.
M
ECONIUM peritonitis is an aseptic chemical peritonitis caused by the entrance of meconium into the peritoneal cavity through a perforation in the intestinal tract during the late intrauterine or early neonatal period. In about one-half of the cases positive evidence of organic intestinal obstruction with perforation can be found, while in the other 50 per cent of cases no demonstrable obstruction or area of perforation can be found, indicating that many of the perforations probably close before birth. The term "meconium peritonitis" is restricted to those cases in which meconium, calcified plaques, and usually foreign body giant cells are found in the peritoneum (Figs. 1 and 2). Many of the cases reported in the literature show some degree of abdominal distension, mostly from gas with minor degrees of ascites, but seldom is the abdominal distention from ascitic fluid of sufficient degree to produce difficulty in delivery. 1 • 3 The following is a report of such a case. History and Physical Examination.-The mother, a 23-year-old white gravida iii, para ii, was admitted to the hospital on July 29, 19561 in active labor. Her prenatal course had been entirely normaL She gave no history of past illnesses. Her previous pregnancies had ended normally with normal infants. Physical examination on admission revealed a pregnant white woman, near term, in active labor. The fetus was estimated to weigh 8 pounds, and was in the left occipitotransverse position at 0 station. The cervix was 7 em. dilated. The fetal heart rate was 138 per minute and regular. The pelvis was clinically judged to be adequate. A short time after admission, the cervical dilatation had progressed to 9 em., and the patient was taken to the delivery room in anticipation of a normal delivery. Labo,r and Delvvery.-The first stage of labor was promptly completed but the second stage was prolonged, requiring some 20 to 30 contractions to bring the head from 0 station to the perineal floor. When the head began to crown, a shallow midline episiotomy was made and the head was delivered with ease until the chin was ready to present. At this point moderate difficulty was encountered. It seemed the fetus would not descend sufficiently to allow the chin to deliver adequately. After the chin was delivered, an attempt was made to deliver the anterior shoulder with the next pain; however, this could not be accomplished. '!'he posterior arm and shoulder were delivered with considerable difficulty and the fetus was rotated so that the anterior shoulder became posterior, and again difficulty was encountered in delivering the second arm und shoulder. Fracture of both clavicles was produced during delivery of the shoulders and arms. From this point it was impossible to complete the de· livery even with strong traction and firm fundal pressure. The possibility o£ Siamese twins, or a tumor of the fetal abdomen or sacral region was entertained. Delivery to this point had been accomplished under pudendal block with nitrous oxide supplement. Portable x-ray examination revealed a single fetal skeleton with no abnormalities. No caldfied or soft tumor masses could be identified. 1247
1248
\\'ALl.
\n1
J. Obst.
& Gync:c.
Deft>mher.
1CJ~9
With the patient now wuler general auesthe~ia, the operator's hand wa~ placed up along the curve of the sacrum and it was ascertained that the abdomen of the fetus was ma rkedly distended . By this time the infant had died and it was decided to decompress the abdominal distention by an incision into th e abdomen with long scissors. Before this was do ne, a final attempt to deliver by means of strong traction and f unrlal pressure was tried and this time tile female infant was delivered rat her precipitously. lmruediately after delivery it waR noted t.loat. a large qua ntity of stmw·colored fiuid was eo ming fw m t.he vagina of the infant.. Further exam ination revealed a perforation in th e wl- I'I'~~ i o n of the abdomen and subsequent delivery. A third degree extension of the midline epi~ i otomy ll'as repaired and the mn ther 's IJ O~t · partum CO UJ'Sil was entirely satisfaetory.
Fig-. 1.
l!'ig-. .,
Fig. !.-Photomicrograph of liver showing thick fibrinous adhesion s over the surface in which a la rge qua ntity o r calcium can be seen. Fig. ~.-Photomicrograph of cross llection of intestine showing the fibrinous arlhesionH on periton ea l surface with inte rmingled fl eck s of calc ium.
A ·utopsy Findings.- Externally, the infant appeared to l>e normal except for a mark!>dly
124~)
\"olume 78
Number 6
Pathological Diagnosis.-The diagnosis was meconium peritonitis, diffuse, marked, point of perforation not identified; and ascites, marked, due to a hove featur~>~.
Comment
The incidence of meconium peritonitis is uncommon. The occurrence of meconium peritonitis with ascites resulting in dystocia is even less common. The diagnosis of this condition before the second stage of labor is difficult and frequently will be missed even when x-rays are taken. These babies usually die during the second stage after the head has been delivered. If the diagnosis could be made before the second stage of labor, delivery by cesarean section would be the method of choice and probably a viable infant would be obtained; however, this infant vvould still face the hazard of laparotoray to release adhesions and close the perforation if it is still present. Summary
A case of meconium peritonitis with ascites resulting in dystocia sented. References "1
.1.
f't_
___
vamp, ..n,..., auu
'--nuuen.~,
"1llr
lv.t.
TT
n.:
... .-..
,t.
run .
....1 • .Vl::-3.
or.n.
vnuu. -,o: vttv,
2. Franklin, A. W., and Hosford, J.P.: Brit. M . .T. 2: 251, 1952. 3. Lattes, R.: AM. J. 0BST. & GYNEC. 46: 149, 1943. 4635
WYANDOTTE
KANSAS CITY 12, Mo.
..
..-..r.
_1!-14~J.
IS
pre-
A.
WALL,
M.D.,
KANSAS CITv,
Mo.
M
ECONIUM peritonitis is an aseptic chemical peritonitis caused by the entrance of meconium into the peritoneal cavity through a perforation in the intestinal tract during the late intrauterine or early neonatal period. In about one-half of the cases positive evidence of organic intestinal obstruction with perforation can be found, while in the other 50 per cent of cases no demonstrable obstruction or area of perforation can be found, indicating that many of the perforations probably close before birth. The term "meconium peritonitis" is restricted to those cases in which meconium, calcified plaques, and usually foreign body giant cells are found in the peritoneum (Figs. 1 and 2). Many of the cases reported in the literature show some degree of abdominal distension, mostly from gas with minor degrees of ascites, but seldom is the abdominal distention from ascitic fluid of sufficient degree to produce difficulty in delivery. 1 • 3 The following is a report of such a case. History and Physical Examination.-The mother, a 23-year-old white gravida iii, para ii, was admitted to the hospital on July 29, 19561 in active labor. Her prenatal course had been entirely normaL She gave no history of past illnesses. Her previous pregnancies had ended normally with normal infants. Physical examination on admission revealed a pregnant white woman, near term, in active labor. The fetus was estimated to weigh 8 pounds, and was in the left occipitotransverse position at 0 station. The cervix was 7 em. dilated. The fetal heart rate was 138 per minute and regular. The pelvis was clinically judged to be adequate. A short time after admission, the cervical dilatation had progressed to 9 em., and the patient was taken to the delivery room in anticipation of a normal delivery. Labo,r and Delvvery.-The first stage of labor was promptly completed but the second stage was prolonged, requiring some 20 to 30 contractions to bring the head from 0 station to the perineal floor. When the head began to crown, a shallow midline episiotomy was made and the head was delivered with ease until the chin was ready to present. At this point moderate difficulty was encountered. It seemed the fetus would not descend sufficiently to allow the chin to deliver adequately. After the chin was delivered, an attempt was made to deliver the anterior shoulder with the next pain; however, this could not be accomplished. '!'he posterior arm and shoulder were delivered with considerable difficulty and the fetus was rotated so that the anterior shoulder became posterior, and again difficulty was encountered in delivering the second arm und shoulder. Fracture of both clavicles was produced during delivery of the shoulders and arms. From this point it was impossible to complete the de· livery even with strong traction and firm fundal pressure. The possibility o£ Siamese twins, or a tumor of the fetal abdomen or sacral region was entertained. Delivery to this point had been accomplished under pudendal block with nitrous oxide supplement. Portable x-ray examination revealed a single fetal skeleton with no abnormalities. No caldfied or soft tumor masses could be identified. 1247
1248
\\'ALl.
\n1
J. Obst.
& Gync:c.
Deft>mher.
1CJ~9
With the patient now wuler general auesthe~ia, the operator's hand wa~ placed up along the curve of the sacrum and it was ascertained that the abdomen of the fetus was ma rkedly distended . By this time the infant had died and it was decided to decompress the abdominal distention by an incision into th e abdomen with long scissors. Before this was do ne, a final attempt to deliver by means of strong traction and f unrlal pressure was tried and this time tile female infant was delivered rat her precipitously. lmruediately after delivery it waR noted t.loat. a large qua ntity of stmw·colored fiuid was eo ming fw m t.he vagina of the infant.. Further exam ination revealed a perforation in th e wl-
Fig-. 1.
l!'ig-. .,
Fig. !.-Photomicrograph of liver showing thick fibrinous adhesion s over the surface in which a la rge qua ntity o r calcium can be seen. Fig. ~.-Photomicrograph of cross llection of intestine showing the fibrinous arlhesionH on periton ea l surface with inte rmingled fl eck s of calc ium.
A ·utopsy Findings.- Externally, the infant appeared to l>e normal except for a mark!>dly
124~)
\"olume 78
Number 6
Pathological Diagnosis.-The diagnosis was meconium peritonitis, diffuse, marked, point of perforation not identified; and ascites, marked, due to a hove featur~>~.
Comment
The incidence of meconium peritonitis is uncommon. The occurrence of meconium peritonitis with ascites resulting in dystocia is even less common. The diagnosis of this condition before the second stage of labor is difficult and frequently will be missed even when x-rays are taken. These babies usually die during the second stage after the head has been delivered. If the diagnosis could be made before the second stage of labor, delivery by cesarean section would be the method of choice and probably a viable infant would be obtained; however, this infant vvould still face the hazard of laparotoray to release adhesions and close the perforation if it is still present. Summary
A case of meconium peritonitis with ascites resulting in dystocia sented. References "1
.1.
f't_
___
vamp, ..n,..., auu
'--nuuen.~,
"1llr
lv.t.
TT
n.:
... .-..
,t.
run .
....1 • .Vl::-3.
or.n.
vnuu. -,o: vttv,
2. Franklin, A. W., and Hosford, J.P.: Brit. M . .T. 2: 251, 1952. 3. Lattes, R.: AM. J. 0BST. & GYNEC. 46: 149, 1943. 4635
WYANDOTTE
KANSAS CITY 12, Mo.
..
..-..r.
_1!-14~J.
IS
pre-