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GYNAECOLOGICAL AND OBSTETRIC IMAGING Table of Contents   
Year : 2004  |  Volume : 14  |  Issue : 3  |  Page : 261-263
Images : Prenatal sonographic features of meconium peritonitis


Department of Radiodiagnosis, G.T.B Hospital Campus, Dilshad Garden, Delhi-110095, India

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   Abstract 

Prenatal sonographic findings in meconium peritonitis are described with illustrations. The characteristic findings include polyhydramnios, fetal ascites, and echogenic calcific foci with distal shadowing

Keywords: prenatal diagnosis, Meconium peritonitis, Ultrasound

How to cite this article:
Gupta R, Upreti L, Bhargava S K, Jain S, Shikha D. Images : Prenatal sonographic features of meconium peritonitis. Indian J Radiol Imaging 2004;14:261-3

How to cite this URL:
Gupta R, Upreti L, Bhargava S K, Jain S, Shikha D. Images : Prenatal sonographic features of meconium peritonitis. Indian J Radiol Imaging [serial online] 2004 [cited 2019 Jul 24];14:261-3. Available from: http://www.ijri.org/text.asp?2004/14/3/261/28598

   Introduction Top


Meconium peritonitis is an aseptic chemical peritonitis resulting from any cause. The prevalence of neonatal meconium peritonitis is estimated to be 1 in 35,000 live births [1]. Characteristic findings are seen on prenatal sonography, allowing a confident diagnosis. This enables the obstetrician and neonatologist to plan the intrapartum and postnatal management.

A 21 year old primigravida, having amenorrhea for approximately six months presented with dyspnea and intermittent abdominal pain. She was a known case of rheumatic valvular disease. On clinical examination the patient was found to be in cardiac failure along with preterm onset of labour. The uterus was tense and fetal parts were felt with difficulty, thus possibility of hydramnios was raised.Sonography confirmed presence of polyhydramnios with a 25-week live intrauterine pregnancy [Figure - 1]. Fetal ascites was present [Figure - 2]. There was evidence of clumped bowel loops forming a dense echogenic mass in the abdomen with distal acoustic shadowing [Figure - 3]. Multiple highly echogenic foci were seen on the visceral peritoneal surface of liver and the parietal peritoneum. [Figure - 4]. No evidence of dilated bowel was seen. Based on these findings a diagnosis of meconium peritonitis was made. Patient went into preterm labour and a stillborn male fetus was delivered. Gross examination of the fetus revealed a distended abdomen. Autopsy was conducted which confirmed the presence of fetal ascites. Multiple plaques of calcified meconium were seen adhered to the parietal peritoneum and surface of liver. There was presence of clumped matted bowel. Distal jejunal atresia was present with evidence of perforation just proximal to the atretic segment. Pancreas was normal.


   Discussion Top


Meconium peritonitis results from prenatal bowel perforation and almost always involves small bowel [1]. Prenatal bowel perforation usually occurs proximal to some form of obstruction, although this cannot always be demonstrated [2]. Intestinal stenosis or atresia and meconium ileus account for 65% of the cases. Other causes include volvulus, internal bowel hernia, intussusception, congenital bands, Meckel's diverticulum, vascular insufficiency, cystic fibrosis, Hirschsprung's disease, intrauterine infection and unknown causes [1]. Following bowel perforation, meconium and digestive enzymes are extruded into the peritoneal cavity inciting an intense chemical peritonitis. Within days, giant cells and histiocytes surround the meconium, resulting in foreign body granulomas and calcification. Over time the inflammatory response may completely seal the perforation. 15-40% of neonates with meconium peritonitis are reported to have cystic fibrosis [3].

A spectrum of sonographic findings has been described in meconium peritonitis depending on the underlying bowel disorder, the inflammatory response and the time since perforation [3]. As some form of bowel obstruction is present in most of these cases, ultrasonography shows evidence of polyhydramnios. This finding is seen more often in cases with proximal bowel obstruction [4].Extrusion of the meconium into the peritoneal cavity produces ascites which outlines the abdominal viscera. In case of meconium peritonitis ascites may be seen anteriorly in peritoneal cavity with matted echogenic bowel loops forming a posterior mass.Intraperitoneal calcifications are the most common and characteristic finding. These calcifications presumably occur during the healing process and appear as highly echogenic linear or clumped foci in the abdomen or pelvis. Calcification may be seen on the surface of the liver [5]. Rarely, meconium calcifications may also be observed intraluminally in association with distal bowel obstruction, usually an anorectal atresia. Sonography is efficacious in the detection of diffuse small foci of calcification [6], Presence of distal shadowing conclusively establishes the presence of calcification, but it may not be seen in all the cases. Acoustic shadowing from small-calcified foci may be difficult to demonstrate, in which case meconium peritonitis should be distinguished from echogenic foci that may be transiently observed in the normal fetal gut due to inspissated meconium. Studies suggest that abdominal calcification is seen less often in fetuses with cystic fibrosis [3], perhaps because of lack of pancreatic enzymes. The inflammatory response may seal the perforation or the meconium may be walled off forming a meconium pseudocyst. Other findings that may be seen on sonography include bowel dilatation and fetal hydrops [6].

The differential diagnosis includes entities, which cause fetal ascites associated with intra-or-extra hepatic calcification. Extra hepatic calcification may be due to hydrometrocolpos. In the latter, secretions may leak from the  Fallopian tube More Detailss to incite an adhesive peritonitis similar to meconium peritonitis. Neonatal bile ascites is associated with common bile duct stones and biliary tract perforation. Intrahepatic calcification, hepatomegaly and ascites may be due to transplacental infection by toxoplasmosis and cytomegalovirus. Hepatic hemangioma may calcify and produce congestive heart failure due to shunting. Similar picture may be caused by a calcified ruptured hepatoblastoma with hemoperitonium [2]

According to sonographic findings in utero, the disease has been classified into three types. Type I (massive Meconium ascites); type II (giant pseudocyst) and type III (calcification and/or small pseudocyst). Studies reveal that type I and II patients are at higher morbid risk, as ventilatory failure may occur due to elevated diaphragm, fetal hydrops or circulatory failure may be precipitated due to massive meconium ascites [6].

Prenatal diagnosis of meconium peritonitis has considerably improved the post natal outcome in these cases[2]. The affected infant can be delivered if pulmonary maturity has been reached or the fetus is >34 weeks gestation [1]. Early clinical awareness allows preparation for a) dystocia due to fetal abdominal distension, b) respiratory distress and disseminated intravascular coagulation, which commonly accompany massive fetal ascites, c) surgical repair of the bowel perforation, since bacterial contamination of the sterile peritonitis may occur rapidly following birth and d) testing to exclude cystic fibrosis [2].

 
   References Top

1.Seow KM, Cheng WC, Yeh ML et al. Prenatal diagnosis of meconium peritonitis in a twin pregnancy after intracytoplasmic sperm injection: A case report. J Reprod Med. 2000; 45: 953-956.  Back to cited text no. 1    
2.Blumenthal DH, Rushovich AM, Williams RK et al. Prenatal sonographic finings of meconium peritonitis with pathologic correlation. J Clin ultrasound 1982; 10: 350-352.  Back to cited text no. 2    
3.Foster MA. Nyberg DA, Mahony BS et al, Meconium peritonitis: Prenatal sonographic findings and their clinical significance. Radiology 1987; 165: 661-665.  Back to cited text no. 3    
4.Pierro A, Cozzi F, Colarossi G et al. Does fetal gut obstruction cause hydramnios and growth retardation? J Pediatr Surg 1987; 22: 454-457  Back to cited text no. 4    
5.Shwimer SR,Vanley GT,Reinke RT.Prenatal diagnosis of cystic meconium peritonitis.J Clin Ultrasound 1984;12:37-39.  Back to cited text no. 5    
6.Kamata Shinkichi, Nose Keisuke, Ishikawa Shiroh et al. Meconium peritonitis in utero. Pediatr Surg Int 2000; 16: 377-379.  Back to cited text no. 6    

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Correspondence Address:
S K Bhargava
E-3, G.T.B Hospital Campus, Dilshad Garden, Delhi-110095
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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