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Surgical emergency in the fetus as indication for cesarean section
333
Int J Gynecol Obster, 1992, 39: 333-339
International Federation of Gynecology and Obstetrics
Letters to the Editor Surgical emergency in the fetus as indication for cesarean section To the Editor
May 21st, 1992
The human fetus has for centuries remained a medical recluse in an opaque womb. With the rapid strides in technical development of ultrasonic equipment and the increasing expertise of the ultrasonographer, it is now possible to make much earlier and more accurate intrauterine diagnoses of fetal anatomical malformations with a noninvasive technique, safe for the fetus and mother and to take ethical and clinical decisions concerning the timing and method of delivery [3-41. A 29-year-old woman, who had delivered a normal girl 5 years earlier, was under constant supervision at a nephrological outpatient clinic because of chronic glomerulonephritis. Before the present pregnancy the blood tests were: creatinine 1.7 mg% and urea 64 mg%. The pregnancy developed normally and ultrasonography performed on the 17th week showed a completely normal fetus. At week 34, because of suspected polyhydramnios, sonography was performed which revealed a female fetus compatible with the pregnancy age, but a mass of 5 x 7 cm was noted in the center of the abdomen and near it some moderately dilated loops of the bowel (Fig. 1). The stomach, kidneys and bladder appeared normal. Three days later another sonograph was performed. The size and consistency of the mass had not changed but the bowel was considerably dilated with vigorous peristalsis. Amniography was inconclusive and the amniotic fluid examination for the fetus lung maturation showed a maturation corresponding to the 38th Keywords: Pregnancy; Chronic glomerulonephritis; section; Small bowel obstruction.
Cesarean
002Q-1292l92/%05.00 @ 1992 International Federation of Gynecology and Obstetrics Printed and Published in Ireland
week of pregnancy. Bile acids and alpha-fetoprotein were within the normal range. On repeated ultrasonography, the impression was that the mass was most probably emerging from the alimentary tract or occluding it. The rapid deterioration as demonstrated by sonography and the possibility of perforation due to obstruction [l] was the reason for termination of the pregnancy. Since we knew from the amniotic fluid test that lung maturation had been achieved, we explained the situation to the mother and she agreed to terminate the pregnancy by a cesarean section. The abdomen of the newborn was found to be distended and a hard mass was palpable in the right upper abdomen. One hour later the newborn child had a barium enema that revealed a complete obstruction of the small bowel leading to a dead-end a few centimeters beyond the ileocecal valve. Dilated loops of the small bowel were prominent. The child was operated on and a huge conglomerated mass of gangrenous small bowel was found adherent to the lower surface of the liver
Fig. 1. Sonograph of a 34-week-old fetus demonstrates a mass of 5 x 7 cm and moderate enlargement of the bowel. Int J Gynecol Obstet 39
334
Letters to the Editor
Fig. 2. bowel.
The incarcerated adherent mass of gangrenous small
(Fig. 2). Inside the mass a collection of pus and necrotic tissue was found caused by a microperforation. The gangrene was caused by volvulus of the loops around the atretic, thread-like bowel. The mass and the necrotic tissue were removed and a temporary ileostomy was performed. Three months later the continuity of the bowel was restored and the child is now thriving normally. The possibility of performing effective surgical procedures to correct fetal malformations gives a new trend to the field of prenatal diagnosis. Some of these malformations are amenable to treatment before term because early detection and recognition of the malformations will influence the management of pregnancy and delivery, prenatal diagnosis of these disorders assumes practical clinical importance. In the present case, an abdominal mass was detected in the fetus involving an anomaly of the terminal ileum and causing obstruction of the bowel. Only a few cases of this localization have been described. Jassani et al. [4] published the largest series of fetal anomalies of the gastrointestinal tract recognized prenatally, but of the 9 cases only 1 was a case of small bowel obstruction due to jejuno-ileal atresia and volvulus, with perforation of the distal ileum.
Int J
Gynecol Obstet 39
Rapid deterioration observed on sonography influenced the mode of delivery toward elective cesarean section rather than vaginal delivery. The ability to detect fetal malformations and the possibility of treating them by medical or surgical procedures raise ethical and moral problems and it would be unwise to resolve them in favor of the fetus [2] even if improvements in fetal therapy will establish a stronger ground to protect the affected fetus’ right to life. The statement of Fletcher [2] seems to hit the target: ‘The fetus with treatable defect could not be fully considered a patient until separate from the mother’ and choices about treatment ought to be made only with the mother’s informed consent. I. Bayer N. Samuel* Cb. chainloff
Departments of Surgery ‘A’ and *Obstetrics and Gynecology Hasharon Hospital, Golda Medical Center Petah-Tiqva and Tel Aviv University Medical School, Israel
References Baxi LV, Yeh MN, Blanc WA, Schullinger JN: Anteparturn diagnosis and management of in utero intestinal volvulus with perforation. New Engl J Med 308: 1519, 1983. Fletcher JC. The fetus as patient: Ethical issues. J Am Med Assoc 246: 712, 1981. Harrison MR, Adjick NS: The fetus as a patient. Surgical considerations. Ann Surg 213: 219, 1991. Hobbins JC, Grannum PAT, Berkowitz RL, Silverman R, Mahoney MJ: Ultrasound in the diagnosis of congenital anomalies. Am J Obstet Gynecol 134: 331, 1979. Jassani MN, Gauderer MWL, Fanaroff AA, Fletcher B, Merkatz IR: A perinatal approach to the diagnosis and management of gastrointestinal malformations. Obstet Gynecol 59: 33, 1982. Correspondenceto: I. Bayer Department of Surgery, ‘A’ Hasbaroa Hospital Petah-Tiqva 49372 P.O.B. 121, Israel
Int J Gynecol Obster, 1992, 39: 333-339
International Federation of Gynecology and Obstetrics
Letters to the Editor Surgical emergency in the fetus as indication for cesarean section To the Editor
May 21st, 1992
The human fetus has for centuries remained a medical recluse in an opaque womb. With the rapid strides in technical development of ultrasonic equipment and the increasing expertise of the ultrasonographer, it is now possible to make much earlier and more accurate intrauterine diagnoses of fetal anatomical malformations with a noninvasive technique, safe for the fetus and mother and to take ethical and clinical decisions concerning the timing and method of delivery [3-41. A 29-year-old woman, who had delivered a normal girl 5 years earlier, was under constant supervision at a nephrological outpatient clinic because of chronic glomerulonephritis. Before the present pregnancy the blood tests were: creatinine 1.7 mg% and urea 64 mg%. The pregnancy developed normally and ultrasonography performed on the 17th week showed a completely normal fetus. At week 34, because of suspected polyhydramnios, sonography was performed which revealed a female fetus compatible with the pregnancy age, but a mass of 5 x 7 cm was noted in the center of the abdomen and near it some moderately dilated loops of the bowel (Fig. 1). The stomach, kidneys and bladder appeared normal. Three days later another sonograph was performed. The size and consistency of the mass had not changed but the bowel was considerably dilated with vigorous peristalsis. Amniography was inconclusive and the amniotic fluid examination for the fetus lung maturation showed a maturation corresponding to the 38th Keywords: Pregnancy; Chronic glomerulonephritis; section; Small bowel obstruction.
Cesarean
002Q-1292l92/%05.00 @ 1992 International Federation of Gynecology and Obstetrics Printed and Published in Ireland
week of pregnancy. Bile acids and alpha-fetoprotein were within the normal range. On repeated ultrasonography, the impression was that the mass was most probably emerging from the alimentary tract or occluding it. The rapid deterioration as demonstrated by sonography and the possibility of perforation due to obstruction [l] was the reason for termination of the pregnancy. Since we knew from the amniotic fluid test that lung maturation had been achieved, we explained the situation to the mother and she agreed to terminate the pregnancy by a cesarean section. The abdomen of the newborn was found to be distended and a hard mass was palpable in the right upper abdomen. One hour later the newborn child had a barium enema that revealed a complete obstruction of the small bowel leading to a dead-end a few centimeters beyond the ileocecal valve. Dilated loops of the small bowel were prominent. The child was operated on and a huge conglomerated mass of gangrenous small bowel was found adherent to the lower surface of the liver
Fig. 1. Sonograph of a 34-week-old fetus demonstrates a mass of 5 x 7 cm and moderate enlargement of the bowel. Int J Gynecol Obstet 39
334
Letters to the Editor
Fig. 2. bowel.
The incarcerated adherent mass of gangrenous small
(Fig. 2). Inside the mass a collection of pus and necrotic tissue was found caused by a microperforation. The gangrene was caused by volvulus of the loops around the atretic, thread-like bowel. The mass and the necrotic tissue were removed and a temporary ileostomy was performed. Three months later the continuity of the bowel was restored and the child is now thriving normally. The possibility of performing effective surgical procedures to correct fetal malformations gives a new trend to the field of prenatal diagnosis. Some of these malformations are amenable to treatment before term because early detection and recognition of the malformations will influence the management of pregnancy and delivery, prenatal diagnosis of these disorders assumes practical clinical importance. In the present case, an abdominal mass was detected in the fetus involving an anomaly of the terminal ileum and causing obstruction of the bowel. Only a few cases of this localization have been described. Jassani et al. [4] published the largest series of fetal anomalies of the gastrointestinal tract recognized prenatally, but of the 9 cases only 1 was a case of small bowel obstruction due to jejuno-ileal atresia and volvulus, with perforation of the distal ileum.
Int J
Gynecol Obstet 39
Rapid deterioration observed on sonography influenced the mode of delivery toward elective cesarean section rather than vaginal delivery. The ability to detect fetal malformations and the possibility of treating them by medical or surgical procedures raise ethical and moral problems and it would be unwise to resolve them in favor of the fetus [2] even if improvements in fetal therapy will establish a stronger ground to protect the affected fetus’ right to life. The statement of Fletcher [2] seems to hit the target: ‘The fetus with treatable defect could not be fully considered a patient until separate from the mother’ and choices about treatment ought to be made only with the mother’s informed consent. I. Bayer N. Samuel* Cb. chainloff
Departments of Surgery ‘A’ and *Obstetrics and Gynecology Hasharon Hospital, Golda Medical Center Petah-Tiqva and Tel Aviv University Medical School, Israel
References Baxi LV, Yeh MN, Blanc WA, Schullinger JN: Anteparturn diagnosis and management of in utero intestinal volvulus with perforation. New Engl J Med 308: 1519, 1983. Fletcher JC. The fetus as patient: Ethical issues. J Am Med Assoc 246: 712, 1981. Harrison MR, Adjick NS: The fetus as a patient. Surgical considerations. Ann Surg 213: 219, 1991. Hobbins JC, Grannum PAT, Berkowitz RL, Silverman R, Mahoney MJ: Ultrasound in the diagnosis of congenital anomalies. Am J Obstet Gynecol 134: 331, 1979. Jassani MN, Gauderer MWL, Fanaroff AA, Fletcher B, Merkatz IR: A perinatal approach to the diagnosis and management of gastrointestinal malformations. Obstet Gynecol 59: 33, 1982. Correspondenceto: I. Bayer Department of Surgery, ‘A’ Hasbaroa Hospital Petah-Tiqva 49372 P.O.B. 121, Israel