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Essay: Meconium peritonitis

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ABSTRACT:
Meconium peritonitis is a nonbacterial, chemical inflammation of the peritoneum caused by escape of meconium into the peritoneal cavity, either in fetal life, at the time of delivery, or very shortly after delivery. The escape of meconium is due to an abnormal opening somewhere in the intestine,It is associated with bowel obstruction due to causes such as imperforate lumen, congenital bands, or other anamolies.
A case of meconium peritonitis without obstruction, is here reported for which no definite etiology is found.In our study the infant was asymptomatic had an uneventful postnatal period. Probably the site of perforation got sealed without any sequelae, indicating self limiting process. Such spontaneous and favorable outcome has been described by some authors.
INTRODUCTION:
Meconium peritonitis refers to a sterile chemical peritonitis due to intra-uterine bowel perforation and spillage of fetal meconium into the fetal peritoneal cavity. The estimated prevalence is 1 in 30,000. [1]
Earlier cases of meconium peritonitis were incidental findings while doing Xray pelvimetry in women for suspected fetal macrosomia and congenital malformation.[3,4]. Antenatal diagnosis was reported by Brugman and colleagues.
The most common bowel disorder leading to meconium peritonitis in utero are those resulting in bowel obstruction and perforation such as small bowel atresia, volvulus and meconium ileus. Sometimes cystic fibrosis may be a possible etiological factor. Cystic fibrosis is present in 7.7 ‘ 40 % with meconium peritonitis[2,10,11]. Therefore all such newborns must be screened for cystic fibrosis.
CASE REPORT:
A 23 year old primigravida, married for 1 year had 5 months amenorrhoea.Family history was negative for congenital anamolies.
She was admitted to us in view of deranged liver function tests. Routine antenatal investigations were done. Her blood group was O positive. Routine ultrasonography done in the second trimester showed a single live fetus of 23 weeks gestational age with an anterior placenta.There was evidence of moderate ascitis with septations and echogenic foci [calcifications] over intestinal loops. There was no suggestion of cerebral or hepatic calcification. Pregnancy was supervised and subsequent ultrasonography done in the third trimester showed persistence of the multiple calcified foci over the intestinal loops with ascitis as seen in the previous scan. Calcific densities were also seen over liver and stomach . Bowel loops were not dilated.Fetal kidney, bladder and heart were normal.No obvious perforation was identified.Both parents were counseled regarding the diagnosis and subsequent management plans.
Labor was induced at 36 weeks gestational age.She delivered a baby girl weighing 3 kilogram with normal Apgar score. Baby’s abdomen was soft.After the baby passed meconium spontaneously she was given feed, which was well tolerated. USG of the abdomen revealed a normal scan. X-ray of the abdomen confirmed intra-abdominal calcification consistent with meconium peritonitis.Baby was also evaluated for the possibilty of cystic fibrosis and immunoreactive trypsinogen test was found to be negative.The mother and the baby was discharged on day 14 after delivery. The baby was fine at 4 weeks follow up and baby is fine till date.
DISCUSSION:
Meconium peritonitis is a sterile chemical peritonitis in which an intense inflammation results in calcification along the surface of bowel or peritoneum. In time the inflammatory response may seal the perforation or alternatively may form a calcified pseudocyst or wall of meconium.Diagnosis of meconium peritonitis is rare before 20 weeks because perisitalsis rarely commences before 20th week of gestation.[8]
Prenatal sonographic diagnosis of meconium peritonitis is extremely useful in postnatal management plan.It includes bilateral hydroceles, swollen vulvae, fetal ascites[6], polyhydromnios [11] intra-abdominal mass, bowel dilatation, snow storm appearance [4] highly echogenic linear or clumped foci which represent calcification [3,4]. Fetal ascitis tends to be more echogenic than simple ascitis.[10] In utero identification of meconium peritonitis by USG has important implications for obstetric and neonatal care. Postnatal outcome for such infants depend on the etiology for bowel rupture and the underlying disease
Meconium peritonitis is associated with a 20-30% incidence of prematurity and a 10-20% incidence of polyhydramnios [1]. Pregnancy should be allowed to continue till term depending upon fetal growth and progression of any associated complication .Rarely, dystocia secondary to massive ascites or abdominal distension with meconium has been reported [2,4] .If dystocia is anticipated then caesarean section will be the prefered operation.. Mortality was found to be high in which perforation persisted.[4]She et al [3] studied 115 cases of meconium peritonitis over 20 years with all cases showing intra-abdominal calcification. Forty-one cases had neonatal obstruction. Mortality rate in their study was 42.6%. Kamata et al [4] evaluated 20 cases of meconium peritonitis. Of these 25% had massive ascites, 20% had giant pseudocyst and the remaining had abdominal calcifications or a small pseudocyst. 50% of the fetuses showed dilatation of bowel. Eighteen fetuses had intestinal atresia and two had intestinal obstruction . Mortality rate was 20%[3]. Dirkes et al [5] reviewed their experience of nine cases with meconium peritonitis diagnosed in utero. They had five cases of simple meconium peritonitis that had an uneventful postnatal period. The other four cases had complex peritonitis with dilated bowel loops of whichtwo cases also had meconium cyst. The two cases (22%,2/9) required postnatal surgery.Review of literature showed when the calcifications are isolated, there generally is a favourable neonatal outcome and intervention is not necessary.[11] If ultrasonography is suggestive of meconium peritonitis in utero, the pediatrician should be vigilent to look for early signs of bowel obstruction in the neonate.One of the important factors for improving outcome in such cases is anticipatory recognition of complications. Early recognition and treatment of acid base imbalance, superimposed bacterial peritonitis, and septic shock can prevent death. The timing of delivery should therefore be discussed with paediatrician and paediatric surgeon. Surgery performed within 24 hours in newborns with bowel obstruction may also improve their outcome. However, asymptomatic infants may develop bowel obstruction secondary to adhesions later in childhood which may need an urgent surgical intervention.
In our study the infant was asymptomatic and had an uneventful postnatal period. Probably the site of perforation got sealed without any sequelae, indicating self limiting process. Such spontaneous and favorable outcome has been described by some authors[7,8]. Meconium peritonitis may occur without any underlying cause. The underlying cause may be innocuous and intervention may not be required.
3. Foster MA, Nyberg DA, Mahony BS et-al. Meconium peritonitis: prenatal sonographic findings and their clinical significance. Radiology. 1987;165 (3): 661-5.
4. Berrocal T, Lamas M, Gutie??rrez J et-al. Congenital anomalies of the small intestine, colon, and rectum. Radiographics. 19 (5): 1219-36.
6. Nam SH, Kim SC, Kim DY et-al. Experience with meconium peritonitis. J. Pediatr. Surg. 2007;42 (11): 1822-5.
10. Entezami M, Albig M, Knoll U et-al. Ultrasound Diagnosis of Fetal Anomalies. Thieme. (2003) ISBN:1588902129.
11. Mcnamara A, Levine D. Intraabdominal fetal echogenic masses: a practical guide to diagnosis and management. Radiographics. 25 (3): 633-45
1. Kalayoglu M, Sieber WK. Rodnan JB et al. Meconium ileus: Acritical review of treatment and eventual prognosis. J Pediatr Surg 1971;6:290-300.
2. Wall LA. Meconium peritonitis with ascites resulting in dystocia. Am J Obstet Gynecol 1959:78:1247-9.
3. She YY, Song LC. Meconium peritonitis ‘ observations in 115 cases and antenatal diagnosis. Z Kinderchir 1982;37:2-5.
4. Kamata S, Nose K, Ishikawa S et al. Meconium peritonitis in utero. Pediatr Surg Int 2000;16:377-9.
5. Dirkes K, Crombleholme TM, Craigo SD et al. The natural history of meconium peritonitis diagnosed in utero. J Pediatr Surg 1995;30:979-82.
7. DeCurtis M, Martinelli P, Saitt F et al. Prenatal ultrasound diagnosis of meconium peritonitis in a preterm infant. Eur J Pediatr 1983;141:51-2.
8. Herschkowitz S, Mizrahi S, Sujov P. Meconium peritonitis, a benign course in a premature infant. Am J Perinatol ; 1990;7:31-2. Saxena Pinkee et al
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2.Foster,M A Nyberg D.A Mahony,B S Mack,L A Marks,W M And Raabe,R D (1987)Meconium Peritonitis;Prenatal Sonographic Findings And Their Clinical Significance.Radiology.165,661-5.
4.Speck.C R,Moore, T Cand Stout,F E(1962)Antenatal Roentgen Diagnosis Of Meconium Peritonitis.Am J Radio.88,566-70.
5.Brugman,S M,Bjelland,J J Thomasson,J.E,Anderson.S F.Angiles ,R H.(1979).Sonographic Findings With Radiological Correlation In Meconium Peritonitis. J Ctn.Ultrasound.7,305-6.
8. Forouhar,F.(1982)Meconium Peritonitis ;Pathology .Evolution And Diagnosis.Am J Clin.Pahol.78.208-10.
10.Bergman,M G M.Mercus,J M W,And Baars.A M.(1984). Obstetrical And Neonatal Aspects Of A Child With Atresia Of Small Bowel. J Perinatal Med.12 325-32.
11.Finkel,L I And Slovis,T L (1982).Meconium Peritonitis,Intraperitoneal Calcification And Cystic Fibrosis.Pediatr,Radio.12,92-3.

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