Selected case presentation on Mngt.

Of
Fetal bowel obstruction
1

03/25/2023
 By Dr. H/kiros.G
(Gyn-Obs 2nd year resident )
Moderator Dr. Misganaw R4

UOG 03/25/2023
2
 0utline
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 Objective
 Case Summary
 Discussion
 US features of fetal bowel obstruction
 Mngt. of fetal bowel obstruction (jejunal atresia)
 Summary
 Comments
 References
03/25/2023
 Objective
4

 To use case as entry and to discuss on antenatal care of fetus

with bowel obstruction disorders .
 To discuss on Mngt. Of neonate with bowel obstruction
 To learn from each rare cases and to improve our antenatal
care follow-up service

03/25/2023
 Case Summary
5

 MRN 976691
 A.H 28 yrs old married,household mother from Adi-arqay

 Glll Pll ( both alive )

 GA 8 months amenorrhea

 No early mile stone

 ANC follow-up at local HC

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 Con’t…
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 All deliveries was vaginally

Last delivery 6 yrs back at HC uneventful

BG
= UKN
RVI = NR

VDRL= NR

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 Con’t…
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 She referred from 1ry hospital ( Debarik) for the Dx of

prlonged latent + PE with severity features (BP 160/110)+
Twin B fetal ascites and presented with lower abd pain and
dark red cloted Vaginal bleeding of 1 day duration

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 Con’t...
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 No Hx of self or family HTN or DM

 No Hx of RUQ pain,blurry vision , head eache
 No Hx of, light headedness, vertigo, tinnitus.
 No other known chronic illness

03/25/2023
 P/E
 G/A - ASL
 BP - 140/90mmHg , PR=102bpm , RR=22bpm T0 = 36.4
 HEENT - pink conj. NIS
 LGS - No LAP
 CVS - S1& S2 well heard no murmur or gallop
 Chest clear

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 P/E
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 ABD - Term sized gravid uterus

multiple fetal poles are palpable
FHB +ve Twin-A 124, Twin-B 140
mild abdominal tenderness
No contraction

 GUS - Cx 2cm dialated, 60%effeced

station-0 , mid position & medium consistency
 MSS/IS - No edema or pallor
 CNS – COPPT
DTR 2/4
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 Obs U/S
11

Twin A Twin B
 Cephalic  Cephalic
 FHB +ve  FHB +ve
 AGA 31 wks  AGA 32 wks
 EFW 1500 gm  EFW 2060 gm
 FT,FB,FBM seen  FT,FB,FBM seen
 AF 3.4cm (SDP)  AF 6 cm (SDP)
 No gross anomalies  Distended multiple bowel loops
& fetal hydrocele seen
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 Con’t...
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 Con’t…
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 Thin dividing membrane seen

 Doppler for both normal study
Index
 3rd TM TwinPx ( Twin-A cphalic) + Twin-B with dilated multiple
bowel loops 2ry ?

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 Con’t …
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 ASS : 3rd TM twin Px ( Twin A cephalic ) + Twin B fetal BO 2ry ?

+ PE with severity + APH 2ry to mild placenta abruption

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 Done …
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 Admitted to L.W
 U/A – Prot.+2
 CBC – Hct = 40.1% PLT= 203
 OFT - SGOT= 35.6 U/L
- SGPT= 22.2 U/L
- Cr.= 0.4 mg/dL

BG(rh) o+

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 PLAN…
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 Rx:
 Continued Mgso4 maintenance
 Dexamethasone initiated
 Hydralazine if BP >160/110
 Methyldopa 500mg PO BID
 To do CTG ,OFT ,CBC,BG (Rh)
 Follow with PE/E chart

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 Con’t…
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On 4/12/12 at 2:00 PM
 She give SVD
Twin A Twin B
1600gm 2100 gm
Male male
8/9 8/9
Placenta DADC
3rd stage labor managed actively

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 Con’t…
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 Post Delivery
GA – comfortable
V/S – B/P 140/100 , PR – 100 bpm, RR- 22 , T-36.1
HEENT – pink conj, NIS
CHEST - clear
ABD - Flat and moves with respiration
Ux well contracted 20wks sized

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 Con’t…
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 GUS - NCVAT , No Vginal bleeding

 CNS - COPPT
DTR 2/4

 Ass : Immediate postpartum period + improving

 Plan : continue postpartum care & Mngt. of PE

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 Con’t…
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 Neonates sent to NICU

For twin evaluation + low birth weight

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 Ix
21

day 1 3 6
WBC 8100 3400 5300

HCT 39.9% 38% 42%

NEU/PLT 54 52 40

BG(Rh) O+

PLT 191 188 150

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 Con’t…
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Date Ix Result Remark

8/12/12 RBS 80 - 392mg/dl
Bilirubin T 11.5 – 21.8 mg/dl
Bilirubin 0.074 - 2.97 mg/dl
D
Na 142 - 148
K 4.6 – 5.07

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 Con’t…
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Date Ix Result Remark

Cr. 0.5 – 0.79mg/dl
ALB 2.8g/dl
Total prot 4.4g/d
4/12/12 PA-XRAY LBO 2ry to?? Enema
8/12/12 Ultrasound Normal study Unremarkable
8/12/12 PA-XRAY Jejunal atresia ?? Anstomosis

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 Con’t...
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 Con’t…
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 P1 : Late preterm (34wks BS) + Low birth wt.(2.1kg) +

AGA + twin B + moderate discordance ( wt -23.8% )

 P2 : LBO 2ry to meconium plug syndrome + hyper

bluribinemia 2ry to LBO + NEC

 P3 : High intestinal obstruction 2ry to jejunal atresia /stenosis

03/25/2023
 Con’t…
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 On 10/12/12 (6 days of age)

 Laparotomy was done for an indication

of SBO 2ry to jejunal atresia

IOF : Jejunal artesia christmas tree deformity
(typelllb) with microcolon
Done: Excision of proximal bulbous end , spatulation of distal
segment & end to end anastomosis with single layer.

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 Vital sign follow-up chart
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 After discharged on 24/12 /12 he passed away

6 days stay in Debarik 1° hospital

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 Con’t…
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03/25/2023
 Introduction
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 Bowel obstruction, also known as intestinal obstruction, is a

mechanical or functional obstruction of the intestines which
prevents the normal movement of the products of digestion

 Fetal Bowel obstructions are relatively rare and occur in

1 of 3000 -5000 live births

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 The stomach is visible in nearly all fetuses after 14 weeks

gestation
 If the stomach is not seen during initial evaluation, the
examination is repeated, and targeted sonography should
be consider

Williams 25ed

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o Bowel appearance changes with fetal maturation.

o Bowel that appears as bright as fetal bone confers

a slightly greater risk for underlying gastrointestinal
malformations, for cystic fibrosis, for trisomy 21, and for
congenital infection such as cytomegalovirus

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 Con’t...
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Journal of Maternal-Fetal & Neonatal Medicine /2020/

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 Atresia and stenosis are thought to be a consequence of an ischemic

event at the level of the mesenteric artery
 The incidence of bowel stenosis and atresia is 2–3:10.000 births

03/25/2023
 US features of the intestinal atresia
38

 Multiple dilated bowel loops

 active peristalsis

 Polyhydramnios

 Hyperechogenic bowel

 Enlarged stomach

 The first sign may be the

presence of a single bowel loop

diameter above 7 x 3 x 15
and with hyperechoic walls
03/25/2023
 Jejunoileal atresia
39

 proximal jejunum in 31%

 distal jejunum in 20%,

 proximal ileum in 13%

 distal ileum in 36%.

 In 6% of the cases the

Atresia interests different

intestinal segments.
.

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 Types of jejunoileal atresia
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Callens 5th ed 03/25/2023

 Esophageal atresia:
43

 1:2500 - 4000 live births

 Absent stomach
 Dilatation of the proximal tract
of the esophagus
( pouch sign ) 9/9,1/6
 Polyhydramnios
 Single umbilical artery
3/450

Callen 5th ed
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 Con’t…
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 Con’t…
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 Five types of esophageal atresia ( A,B,C,D,E,)

 Failed division at 8 weeks of gestation of the primitive
intestine in the ventral tracheobronchial portion and in the
dorsal intestinal portion.
 Prenatal diagnosis is possible in only 10% of the cases

Donald school text book of US Gyn-obs

2018 4th ed & callen 5th ed

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03/25/2023
 Duodenal atresia
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 1:2500 - 10000
 double bubble sign
 Polyhydramnios

 Failure of canalization of the

primitive bowel 11th wks GA
 Focal eschemia
 External factors
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 Con’t…
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03/25/2023
 Colon obstruction
51

 Distal occlusion & dilated

intestinal loops
 Increased peristalsis
 intraluminal echogenic
material

 Bowel obstruction is usually

detected in the third trimester

03/25/2023
 Echogenic Bowel
52

 Echogenic Bowel 0.2 – 2 %

 Sonographically,“echogenic bowel”
is defined asechogenicity of the
bowel loops equal to or greater
than the density of the iliac wing

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 Con’t….
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 About 75% of the cases “echogenic bowel” is a normal

finding with no pathological significance.
 It must also be stressed that the use of high frequencies
(5/8 MHz) and second harmonic produce an increased
echogenicity

Donald school textbook of Gyn-Obs US

2018 4th ed & callen 5th.

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 Con’t...
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 Journal of US in medicine
 Evaluated how ultrasound transducer frequency affected the
appearance of the fetal bowel.

 Patients with known fetal anomalies, abnormal biochemical

screening results, or a history of cystic fibrosis were excluded
 Images of the fetal abdomen were obtained in all patients
using a single multi-Hertz transducer, with transducer
frequencies set at 5 MHz and 8 MHz

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 Con’t...
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 Images were read separately by two radiologists, blinded to

patient name and transducer frequency.

 . Observers rated the presence or absence of echogenic

bowel, defined as bowel with echogenicity greater than or
equal to that of adjacent bone

 Using the 8 MHz = 31% having echogenic bowel, whereas

using the 5 MHz only 3% of the cases as having echogenic
bowel 
03/25/2023
 Meconium Peritonitis:
56

 1 ： 20,000 – 30,000
 Intrabdominal diffuse hyperecogenicity
 Calcifications
 Ascites
 bowel dilatation
 Chemical peritonitis
 Frequently associated with
Cystic fibrosis and
Outcome Usually poor

Donald School Textbook of

ULTRASOUND IN OBSTETRICS AND
GYNECOLOGY 4th ed. 03/25/2023
 Mngt.
57

 Short interval appointment

 Targeted anatomic scan on every appointment
 Multidisciplinary Mngt.
 Continuation or intervention of Px. Depend on clinical
scenario of the Pt.

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58
Con’t…

03/25/2023
 Preoperative management
59

 Gastric decompression
 Fluid management
 Correction of electrolyte abnormalities
 Transfer to a pediatric surgery center
 Radiology: abdominal radiograph, contrast enema, contrast
meal if stenosis suspected
 Assessment for associated malformations
 Prophylactic antibiotics

03/25/2023
 Operative management
60

 Identify type of atresia

 Establish distal patency
 Bulbous component: resect, taper, or plicate if short
residual length
 De-rotate and taper if high jejunal atresia
 Preserve maximal distal bowel
 length – measure residual bowel
 End-to-end single-layer interrupted anastomosis

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 Postoperative management
61

 Gastrointestinal decompression
 Antibiotics
 Parenteral nutrition
 Early graduated enteral feeds: breast, special, or polymeric
feeds

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62
Special problems
 Anastomotic dysfunction
 Short bowel syndrome
 Associated congenital abnormalities

03/25/2023
63
Con’t...

7 days old male neonate born to 34 yrs old Para ll , at GA 32+6 ,

Wt 1.6kg , APGAR 7&8, ANC with 2nd & 3rd TMPx. US Scanning
Laparotomy at 14 days age & passed away after 25 post OP
Parenteral vs enteral feding
03/25/2023
 Summary
64

 Intestinal dilatation
 Intestinal content
 Ascites
 The length and width of dilated bowel loops
 Anatomy and physiology
 Peristalsis

03/25/2023
 Summary
65

 Intraperitoneal calcifications
 Amniotic fluid volume
 Digestive enzymes in the amniotic fluid
 Ultrasound machines
 MRI
 Parents consultation

03/25/2023
 Comment
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 Detecting is timely at 1st visit  Main problem of the case

( fetal ascites ) is not mentioned
 Neonate transfer NICU timely
 Anal examination not
documented or not done
 Documentation is fair
 Referal reason not clear
 Rx according to protocol
Prolong latent vs OFT

03/25/2023
 References
67

1.Donald School Textbook Of Ultrasound In Obstetrics And

Gynecology 2018 4th ed.
2.Williams 25ed.
3. Gabbe 7th ed.
4. Journal of Maternal-Fetal & Neonatal Medicine
5. up-to-date 21.8
6.Callen Gyn-obs US 5th ed.
7. American Pediatric Association 2016
8 Complications In Pediatric Surgery
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K Y O U
TH A N 2 0 13
y e a r
p y n e w
ha p

03/25/2023