Samuel et al., Diagnosis of intestinal obstruction by ultrasound
333
Short communications
J.Perinat.Med.
12(1984) 333
Ultrasound diagnosis and management of fetal intestinal obstruction
and volvulus in utero
N. Samuel, D. Dicker, D. Feldberg, J. A. Goldman
Department of Obstetrics-Gynecology, Golda Meir Medical Center, Petah-Tikva,
and Tel-Aviv University Medical School, Israel
1 Introduction
Curriculum vitae
For many centuries no means were available to
evaluate the human fetus in utero. While amniocentesis, amniography and fetoscopy are all
invasive techniques, fetal anatomy as well as
major congenital malformations currently can be
accurately determined at an early stage with the aid
of non-invasive ultrasonography [8]. Modern ultrasonographic examination of the fetus allows in
utero evaluation of congenital anomalies. Recently
a group of fetal malformations has been added,
namely those amenable to correctable surgery
after birth.
We present a case of severe intestinal obstruction
in utero diagnosed by ultrasonography and corrected by surgery immediately following premature planned delivery by Ceasarean section.
NURITH SAMUEL was
born in 1952, and was
graiuated from Tel-Aviv
University Medical School
in 1978. Subsequently she
has been in training in the
Department of Obstetrics
and Gynecology at the
Golda Meir Medical Center
(Chief: Prof. J. Goldman),
Petah-Tikva, Israel. She is
at the present Senior Resident with a special interest
in ultrasound.
stomach, kidneys and bladder appeared normal.
The mass remained static over the next week, yet a
significant dilatation of the small bowel loops was
obvious (Figs. 3, 4), and peristalsis was markedly
increased. One dilated loop of bowel was observed
2 Case report
to enter the mass (Fig. 5).
H. S., a 31 years old woman was seen in the ultra- The biophysical score of the fetus was normal.
sound clinic of the Golda Meir Medical center in Amniocentesis revealed fetal lung immaturity as
the 33rd week of her second pregnancy because tested by lung profile. Bile acids and alpha-fetoof suspected polyhydramnios. The first pregnancy proteins were within normal range [3, 14]. In view
and delivery were normal. In the 18th week of her of the fetal abdominal mass which most probably
present gestation the ultrasound scan was perfectly represented meconium originating in the small
normal. Sonography at this time revealed mild poly- bowel and the presence of acute progressing
hydramnios and an abdominal mass of 5 χ 7 cms. intestinal dilatation, five days later, with proven
located under the fetal liver (Fig. 1). Slightly fetal lung maturity, a Caesarean section was perdilated intestinal loops were observed (Fig. 2). The formed in order to prevent spontaneous perfora© by Walter de Gruyter & Co. Berlin · New York
334
Samuel et al., Diagnosis of intestinal obstruction by ultrasound
Fig. 1. Ultrasound scan: intraabdominal mass in the fetus Fig. 3. Progressively enlarged intestinal loops after 48
(M: mass; K: kidney; P: placenta; A: amniotic
fluid)
"hours.
Fig. 2. Slightly enlarged loops of small bowel: 33rd week
of pregnancy (L: intestinal loops).
Fig. 4. Same after 72 hours
J.Perinat. Med. 12 (1984)
Samuel et al., Diagnosis of intestinal obstruction by ultrasound
335
3 Comment
The improving technique and range of diagnostic
ultrasonography and ultrasound equipment has
made it possible to detect fetal congenital anomalies early in pregnancy; however, even more
important is the early detection of potentially,
surgically correctable malformations of the fetus.
Indeed, several reports of sporadic cases have been
published recently [1, 2 , 4 , 6 , 7 , 9 , 10, 11, 12, 13,
15, 16, 17,18].
The case described here is one involving an anomaly of the termina ileum. Only few cases of this
localization have been described. In fact, JASSANI
etal. [10] published the largest series of gastrointestinal tract anomalies of the fetus recognized
prenatally; of nine, one was a case of small bowel
obstruction due to jejuno-ileal atresia and volvulus,
with perforation of the distal ileum.
Fig. S. Enlarged intestinal loops penetrating into mass
(arrow).
tion or irreversible ischemia of a wide portion of
small bowel.
The abdomen of the newborn was found to be
distended, and a hard mass was palpated in the
right upper abdomen. Barium enema performed
immediately after delivery revealed a rather narrow large bowel leading to a "dead-end" a few
centimeters beyond the ileocecal valve. Markedly
dilated intestinal loops were seen with a minute
amount of contrast material under the diaphragm
which represented a picture which could correspond to microperforation of the bowel.
.Laparotomy of the baby was performed one hour
after delivery. The operative findings included
mild peritonitis with atresia of the terminal ileum,
and above the atresia, there was a mass of convoluted intestinal loops resulting in volvulus. One
of the loops was adherent to the abdominal wall,
and was filled with thick meconium. This loop was
obviously the mass seen on ultrasonographic scan.
The volvulus was resected, and ileostomy and colostomy were done. The baby recovered rapidly;
repair of the colostomy and ileostomy was performed 2 months after surgery. The baby is at
present in good general condition.
J. Perinat. Med. 12(1984)
Elective Caesarean section rather than a trial at
vaginal delivery was indicated in our case since
immediate surgical correction was considered
necessary. Moreover, this mode of delivery was
considered less traumatic for a premature, handicapped neonate, and cervical and uterine conditions for spontaneous delivery were unfavourable.
Furthermore, the compromised small bowel was
obviously fluid-filled and progressively dilating
to an extent that intestinal ischemic necrosis
and meconium ileus was threatening to lead to
gangrene, intestinal perforation and meconium
peritonitis.
In fact, we believe that it has not hitherto been
mentioned and should be emphasized that although prenatal obstruction may well be a gradual
.process, progress to complete obstruction has a
rather dynamic course. Consequently, regular
ultrasound scans may detect the true course of the
process, and improve the prognosis of the fetus.
It is interesting to note that the biophysical score,
(fetal movements, breathing, tonus, non-stress test,
etc*) during the observation period, and up to the
delivery by Caesarean section, was entirely normal.
In view of the fact that the number of treatable
congenital defects in the fetus is steadily growing,
the ethical issues of the fetus as a patient must
certainly be given consideration [5J.
Samuel et al., Diagnosis of intestinal obstruction by ultrasound
336
4 Conclusions
The prenatal detection of such birth defects permits planning for the optimal
time, site and mode
r
u
The number and types of cases is growing m whom
'
ofde jj v
prenatal diagnosis of correctable fetal anomalies
^'
are made by ultrasonography.
Summary
A case has been described in which the diagnosis of acute
intestinal obstruction of the fetal small bowel was made
antenatally with the aid of ultrasonography. Ceasarean
section was done in the 34th week of pregnancy. One
hour after birth ileostomy and colostomy were performed
Keywords:
after resection of a volvulus in the terminal ileum. Two
months later the ileostomy and colostomy were closed,
and the baby is doing well. The importance of precise
diagnosis of the anomaly in utero is emphasized to avoid
unjustified termination of pregnancy.
Antenatal volvulus in fetus, antenatal ultrasound, correctable fetal anomaly.
Zusammenfassung
Ultraschalldiagnose und Vorgehen bei einem Darmverschluß und Volvulus in utero
Wir haben einen Fall beschrieben, in dem antenatal mit
Hilfe des Ultraschalls ein aktuer Dünndarmverschluß
diagnostiziert wurde. In der 34. Schwangerschaftswoche
erfolgte die Sectio; eine Stunde post partum wurden nach
Resektion eines Volvulus im terminalen Ileum eine Ileo-
stomie und eine Kolostomie angelegt. Nach zwei Monaten
wurde das Kolostoma verschlossen; das Kind gedeiht gut.
Wir möchten nachdrücklich auf die Bedeutung einer
präzisen Diagnose fetaler Anomalien in utero hinweisen.
So können nämlich ungerechtfertigte Schwangerschaftsabbrüche vermieden werden.
Schlüsselwörter: Antenataler Volvulus beim Feten, antenataler Ultraschall, korrigierbare fetale Anomalien.
Resume
Diagnostic echographique et conduite a tenir devant une
occlusion intestinale par volvulus in utero
Les auteurs decrivent une observation au cours de laquelle
le diagnostic chez le foetus d'occlusion intestinale aique du
grele a ete porte pendant la grossesse a l'aide de l'echographie. Une cesarienne a ete effectuee a la 34e semaine
Mots-cles:
de gestation; apres resection de la zone volvulee sur l'ileon
terminal, une heure apres la naissance, on a realise une
ileostomie et une colostomie. Deux mois plus tard la colostomie a ete fermee et le bebe se porte bien. L'importance
du diagnostic precis de l'anomalie in utero est soulignee
afin d'eviter une interruption injustifiee de la grossesse.
Anomalie foetale curable, echographie ant6natale, volvulus antenatal chez le foetus.
Acknowlegments:
Thanks are due to Dr. ABRAMOWITZ and Dr. R. KATZ for their assistance in the interpretation of
ultrasound scans.
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Received December 1, 1983. Revised April 12,1984.
Accepted April 24, 1984.
Nurith Samuel, M.D.
Tel-Aviv University Medical School
Dept. Obstetrics-Gynecology
Golda Meir Medical Center
Petah-Tikva, Israel
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