Prenatal ultrasonographic detection of gastrointestinal obstruction: results from 18 European congenital anomaly registries

Diagnostic accuracy of ultrasound screening for fetal structural abnormalities during the first and second trimester of pregnancy in low-risk and unselected populations

BACKGROUND

Prenatal ultrasound is widely used to screen for structural anomalies before birth. While this is traditionally done in the second trimester, there is an increasing use of first-trimester ultrasound for early detection of lethal and certain severe structural anomalies.

OBJECTIVES

To evaluate the diagnostic accuracy of ultrasound in detecting fetal structural anomalies before 14 and 24 weeks' gestation in low-risk and unselected pregnant women and to compare the current two main prenatal screening approaches: a single second-trimester scan (single-stage screening) and a first- and second-trimester scan combined (two-stage screening) in terms of anomaly detection before 24 weeks' gestation.

SEARCH METHODS

We searched MEDLINE, EMBASE, Science Citation Index Expanded (Web of Science), Social Sciences Citation Index (Web of Science), Arts & Humanities Citation Index and Emerging Sources Citation Index (Web of Science) from 1 January 1997 to 22 July 2022. We limited our search to studies published after 1997 and excluded animal studies, reviews and case reports. No further restrictions were applied. We also screened reference lists and citing articles of each of the included studies.

SELECTION CRITERIA

Studies were eligible if they included low-risk or unselected pregnant women undergoing a first- and/or second-trimester fetal anomaly scan, conducted at 11 to 14 or 18 to 24 weeks' gestation, respectively. The reference standard was detection of anomalies at birth or postmortem.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook study selection, quality assessment (QUADAS-2), data extraction and evaluation of the certainty of evidence (GRADE approach). We used univariate random-effects logistic regression models for the meta-analysis of sensitivity and specificity.

MAIN RESULTS

Eighty-seven studies covering 7,057,859 fetuses (including 25,202 with structural anomalies) were included. No study was deemed low risk across all QUADAS-2 domains. Main methodological concerns included risk of bias in the reference standard domain and risk of partial verification. Applicability concerns were common in studies evaluating first-trimester scans and two-stage screening in terms of patient selection due to frequent recruitment from single tertiary centres without exclusion of referrals. We reported ultrasound accuracy for fetal structural anomalies overall, by severity, affected organ system and for 46 specific anomalies. Detection rates varied widely across categories, with the highest estimates of sensitivity for thoracic and abdominal wall anomalies and the lowest for gastrointestinal anomalies across all tests. The summary sensitivity of a first-trimester scan was 37.5% for detection of structural anomalies overall (95% confidence interval (CI) 31.1 to 44.3; low-certainty evidence) and 91.3% for lethal anomalies (95% CI 83.9 to 95.5; moderate-certainty evidence), with an overall specificity of 99.9% (95% CI 99.9 to 100; low-certainty evidence). Two-stage screening had a combined sensitivity of 83.8% (95% CI 74.7 to 90.1; low-certainty evidence), while single-stage screening had a sensitivity of 50.5% (95% CI 38.5 to 62.4; very low-certainty evidence). The specificity of two-stage screening was 99.9% (95% CI 99.7 to 100; low-certainty evidence) and for single-stage screening, it was 99.8% (95% CI 99.2 to 100; moderate-certainty evidence). Indirect comparisons suggested superiority of two-stage screening across all analyses regarding sensitivity, with no significant difference in specificity. However, the certainty of the evidence is very low due to the absence of direct comparisons.

AUTHORS' CONCLUSIONS

A first-trimester scan has the potential to detect lethal and certain severe anomalies with high accuracy before 14 weeks' gestation, despite its limited overall sensitivity. Conversely, two-stage screening shows high accuracy in detecting most fetal structural anomalies before 24 weeks' gestation with high sensitivity and specificity. In a hypothetical cohort of 100,000 fetuses, the first-trimester scan is expected to correctly identify 113 out of 124 fetuses with lethal anomalies (91.3%) and 665 out of 1776 fetuses with any anomaly (37.5%). However, 79 false-positive diagnoses are anticipated among 98,224 fetuses (0.08%). Two-stage screening is expected to correctly identify 1448 out of 1776 cases of structural anomalies overall (83.8%), with 118 false positives (0.1%). In contrast, single-stage screening is expected to correctly identify 896 out of 1776 cases before 24 weeks' gestation (50.5%), with 205 false-positive diagnoses (0.2%). This represents a difference of 592 fewer correct identifications and 88 more false positives compared to two-stage screening. However, it is crucial to acknowledge the uncertainty surrounding the additional benefits of two-stage versus single-stage screening, as there are no studies directly comparing them. Moreover, the evidence supporting the accuracy of first-trimester ultrasound and two-stage screening approaches primarily originates from studies conducted in single tertiary care facilities, which restricts the generalisability of the results of this meta-analysis to the broader population.

Congenital Duodenal Obstruction: National Trends in Management and Outcomes during the Last Quarter of a Century in Norway

INTRODUCTION

 During the last quarter of a century, new surgical techniques in neonates have been introduced, and neonatal intensive care has developed. Few studies have explored the implementation of new techniques and if outcomes in neonates undergoing gastrointestinal surgery have improved in the last decades. Therefore, this study aimed to investigate possible changes in postoperative outcomes and surgical techniques in all neonates operated for congenital duodenal obstruction (CDO) 1995 to 2020 in Norway.

MATERIAL AND METHODS

 This is a national multicenter retrospective study of all neonates undergoing surgery for CDO in Norway from 1995 to 2020. Results from three periods (1995-2003, 2004-2012, and 2013-2020) were compared. The study was approved by the local data protection officers (2020/13386) and (2020/15125).

RESULTS

 We included 186 patients: 41 in period 1 (1995-2003), 83 in period 2 (2004-2012), and 62 in period 3 (2013-2020). Seventy (38%) neonates had Down syndrome and 104 (62%) had additional malformations/disorders. Birth weight, gender, frequency of Down syndrome, and other malformations/disorders did not differ between the three periods. We observed an increased rate of prenatal diagnosis throughout the study period (p < 0.001). The only change in surgical technique was the increased use of transanastomotic feeding tubes (p < 0.001). Length of stay, postoperative complication rate, days with parenteral nutrition, and 30-day mortality rate were stable over time.

CONCLUSION

 Perioperative treatment and postoperative outcomes in neonates with CDO have been surprisingly unchanged during the last quarter of a century. Only an increased rate of prenatal diagnosis and more frequent use of transanastomotic feeding tubes were observed.

Prenatal diagnosis of fetal digestive system malformations and pregnancy outcomes at a tertiary referral center in Fujian, China: A retrospective study

Fetal digestive system malformations (DSMs) are correlated with chromosomal anomalies. The prenatal diagnosis of DSMs allows for timely treatment and reduces perinatal morbidity and mortality. However, genetic screening for fetal DSMs is rarely reported. This study aimed to investigate genetic etiology and pregnancy outcomes in cases of fetal DSM by analyzing correlations between DSM types and chromosomal anomalies. This retrospective single-center study included 126 fetuses in whom DSMs were detected via prenatal ultrasonography. Genetic etiology was investigated using conventional karyotyping, chromosome microarray analysis (CMA), and whole-exome sequencing (WES). DSMs were categorized as simple DSM (Group A), DSM combined with abnormal ultrasound soft markers (Group B), and DSM combined with comorbidities of other systems (Group C). Abnormal karyotypes were detected in 11/126 (8.7 %) fetuses. Four more pathogenic copy number variants (CNVs) were detected using CMA, increasing the detection rate to 11.9 %. The detection rates significantly differed between the three DSM types (1.78 %, 8.11 %, and 33.33 % in Groups A, B, and C, respectively). The overall adverse pregnancy outcome rate was 33.9 %, and 11.5 %, 23.5 %, and 81.3 %, (P < 0.001), respectively, in Groups A, B, and C. Out of 83 live births, three neonates died, 26 underwent postnatal surgery with 24 favorable outcomes, and 54 did not undergo surgery and were basically normal. Two neonates who underwent WES were diagnosed with CHD7-associated Charge syndrome and JAG1-associated Alagille syndrome, respectively. Our findings demonstrate that fetal DSM is closely related to chromosome aneuploidies, CNVs, and point mutations. The prognoses of most fetuses with simple DSM and those with comorbid abnormal ultrasound soft markers were favorable in the absence of chromosomal anomalies and severe structural malformations, provided they underwent timely surgery as neonates. These findings provide guidance for the prenatal diagnosis and clinical management of fetal DSMs and the genetic counseling of parents.

Congenital small bowel obstruction: Prenatal detection and outcome

OBJECTIVE

To evaluate and compare the outcome of fetuses and neonates with congenital small bowel obstructions (SBO), evaluate the screening performance of prenatal ultrasound for SBO and identify possible risk factors for adverse outcomes.

METHODS

All cases referred to the Amsterdam University Medical Centers between 2007 and 2021 for a prenatal suspected SBO, supplemented by cases of postnatal diagnosis of SBO, were included. The primary outcome was survival after 24 weeks of gestation until the first year of life.

RESULTS

147 cases of SBO were included with a survival rate of 86.2% (119/138) after 24 weeks of gestation until the first year of age. Additional structural or chromosomal anomalies were found to have an increased risk of adverse outcomes. Intrauterine fetal demise occurred in 10/147 (6.8%) cases and 9/147 (6.1%) cases died during postnatal follow-up. The overall positive predictive value of all prenatally diagnosed cases was 91.5%. Surgical correction was performed in 123/128 (96.0%) of the live-born cases.

CONCLUSIONS

Congenital SBO has an overall favorable prognosis, but the outcome is negatively impacted by the possible presence of additional structural or chromosomal anomalies. Fetal monitoring in the early third trimester should be considered, since all cases of Intrauterine fetal demise occurred between 30 and 35 weeks of gestation.

Clinical Presentations and Diagnostic Imaging of VACTERL Association

Background: VACTERL association consists of Vertebral, Anorectal, Cardiac, Tracheo-Esophageal, Renal, and Limb defects. The diagnosis depends on the presence of at least three of these structural abnormalities. Methods: The clinical presentation and diagnostic prenatal imaging of VACTERL association are comprehensively reviewed. Results: The most common feature is a vertebral anomaly, found in 60-80% of cases. Tracheo-esophageal fistula is seen in 50-80% of cases and renal malformations in 30% of patients. Limb defects including thumb aplasia/hypoplasia, polydactyly, and radial agenesis/hypoplasia are present in 40-50% of cases. Anorectal defects, like imperforate anus/anal atresia, are challenging to detect prenatally. Conclusion: The diagnosis of VACTERL association mostly relies on imaging techniques such as ultrasound, computed tomography, and magnetic resonance. Differential diagnosis should exclude similar diseases such as CHARGE and Townes-Brocks syndromes and Fanconi anemia. New insights into genetic etiology have led to recommendations of chromosomal breakage investigation for optimal diagnosis and counseling.

Prenatal Sonography in Suspected Proximal Gastrointestinal Obstructions: Diagnostic Accuracy and Neonatal Outcomes

BACKGROUND

The purpose of this study was to assess diagnostic accuracy and neonatal outcomes in fetuses with a suspected proximal gastrointestinal obstruction (GIO).

METHODS

After IRB approval, a retrospective chart review was conducted on prenatally suspected and/or postnatally confirmed cases of proximal GIO at a tertiary care facility (2012-2022). Maternal-fetal records were queried for presence of a double bubble ± polyhydramnios, and neonatal outcomes were assessed to calculate the diagnostic accuracy of fetal sonography.

RESULTS

Among 56 confirmed cases, the median birthweight and gestational age at birth were 2550 g [interquartile range (IQR) 2028-3012] and 37 weeks (IQR 34-38), respectively. There was one (2%) false-positive and three (6%) false-negatives by ultrasound. Double bubble had a sensitivity, specificity, positive predictive value, and negative predictive value for proximal GIO of 85%, 98%, 98%, and 83%, respectively. Pathologies included 49 (88%) with duodenal obstruction/annular pancreas, three (5%) with malrotation, and three (5%) with jejunal atresia. The median postoperative length of stay was 27 days (IQR 19-42). Cardiac anomalies were associated with significantly higher complications (45% vs 17%, p = 0.030).

CONCLUSIONS

In this contemporary series, fetal sonography has high diagnostic accuracy for detecting proximal gastrointestinal obstruction. These data are informative for pediatric surgeons in prenatal counseling and preoperative discussions with families.

LEVEL OF EVIDENCE

Diagnostic Study, Level III.

Ultrasonographic Imaging of the Fetal Pyloric Sphincter

OBJECTIVES

In this study, we hypothesized that the pyloric sphincter can be directly visualized by ultrasonography in the prenatal period.

METHODS

This study was designed as a cross-section. Single, healthy pregnancies between 18 and 22 weeks of gestation who applied to the Perinatology outpatient clinic for second-level ultrasonography were included in the study. In addition to the demographic characteristics of the participants, fetal pyloric mucosa, fetal pyloric sphincter length, and fetal pyloric sphincter thickness were measured by ultrasonography. Intrarater variability was calculated.

RESULTS

A total of 93 eligible patients were evaluated in the study. The mean age of the participants was 27.25 ± 6.23, and the gestational age was 21.18 ± 0.98. Pylorus imaging and measurements were possible in all fetuses that were in the optimal position. Mean pyloric sphincter length (mm) was 5.32 ± 0.93, pyloric sphincter thickness (mm) was 2.13 ± 0.44, and sphincter muscle thickness (mm) was 1.05 ± 0.24.

CONCLUSIONS

The pyloric sphincter can be easily visualized on a second-trimester ultrasound scan when the appropriate technique is used. This may make an additional contribution to the diagnosis of fetal gastrointestinal tract pathologies.

Fetal intestinal loop dilatation: Follow-up and outcome of a series of 133 consecutive cases (the DILDIG study)

OBJECTIVES

To define the prognostic markers of fetal dilated bowel loops.

METHODS

National non-interventional study of 133 consecutive prenatal observations of dilated loops including ultrasound examinations, complementary laboratory tests, magnetic resonance imaging (MRI), outcomes, and postnatal diagnosis.

RESULTS

One hundred twenty seven cases were classified according to outcome: Group 1, very severe (n = 43), Group 2, children needing specific care (n = 39), and Group 3, healthy children (n = 45). Prenatal ultrasound scan suggested duodenal obstruction in 30 cases, small bowel obstruction in 81, colonic obstruction in 11, and diffuse dilatation in 5. Diameter of dilated loops did not significantly differ between the groups. A poor prognosis was significantly associated with duodenal obstruction, genetic anomalies (53% vs. 21.8%), including aneuploidies or CFTR gene mutations and abnormal amniotic fluid biochemistry (86.4% vs. 38.7%). A good prognosis was associated with regression of dilatation and normal MRI.

CONCLUSION

In this study, postnatal outcomes for fetuses with intestinal dilatation were best predicted by assessing the level of obstruction with prenatal ultrasound and MRI, determining the presence of associated malformations, amniotic fluid biochemical and genetic testing, and monitoring for regression of bowel dilatation. These results should help inform future guidelines on the prenatal and neonatal management of congenital intestinal obstruction.

A Spectrum of Ultrasound and MR Imaging of Fetal Gastrointestinal Abnormalities: Part 1 Esophagus to Colon

Ultrasound (US) and magnetic resonance imaging (MRI) are two modalities for diagnosing fetal gastrointestinal (GI) anomalies. Ultrasound (US) is the modality of choice. MRI can be used as a complementary method. Despite its expanding utilization in central nervous system (CNS) fetal malformation, MRI has not yet been established for evaluation of fetal GI abnormalities. Therefore, more attention should be paid to the clinical implications of MRI investigations following screening by US.

Ultrasonographic Imaging of the Fetal Duodenal Tract

OBJECTIVES

To investigate whether fetal duodenal tract sections can be visualized in the prenatal ultrasonographic examination.

METHODS

This study was designed in cross-section. Healthy singleton pregnant women who applied to the perinatology outpatient clinic for second-level ultrasound scanning between September 2020 and February 2021 were included in the study. Demographic information of the participants was obtained and an ultrasound scan was performed. The fetal duodenal tract was evaluated in three sections, including the pylorus. The fetal duodenal tract was differentiated from adjacent organs by its anatomical location, hyperechoic nature, and presence of fluid in the lumen.

RESULTS

A total of 278 eligible participants between 18 and 22 weeks of gestation were evaluated. While the fetal pylorus was closed in 76.6% of the participants, it was open in 23.4%. Duodenum pars superior, pars descendens, and pars inferior imaging rates were 99.3%, 98.2%, and 95.7%, respectively. It was possible to distinguish these parts from neighboring organs by 99.6%, 100%, and 100%, respectively. While the first, second, and third parts of the duodenum were observed as solid in 42.0%, 58.2%, and 52.2%, respectively, 57.9%, 41.7%, and 47.7% had fluid in the lumen.

CONCLUSION

The fetal duodenal tract can be viewed with prenatal ultrasonography in pregnant women who are not in a dorsoanterior position. This may make an additional contribution to the diagnosis of duodenal obstructions, which is the most common cause of intestinal atresia in prenatal screening.

Congenital duodenal obstruction - Advances in diagnosis, surgical management, and associated controversies

Congenital duodenal obstruction (CDO) occurs due to intrinsic and extrinsic mechanisms but is most often caused by intrinsic duodenal atresia and stenosis. This review will summarize the history, epidemiology, and etiologies associated with the most common causes of CDO. The clinical presentation, complex diagnostic considerations, and current surgical repair options for duodenal atresia and stenosis will also be discussed. Finally, both historical and recent controversies which continue to affect the surgical decision-making in the management of these patients will be highlighted.

Prenatal Detection of Congenital Duodenal Obstruction—Impact on Postnatal Care

Background: Duodenal obstruction is a rare cause of congenital bowel obstruction. Prenatal ultrasound could be suggestive of duodenal atresia if polyhydramnios and the double bubble sign are visible. Prenatal diagnosis should prompt respective prenatal care, including surgery. The aim of this study was to investigate the rate and importance of prenatally diagnosed duodenal obstruction, comparing incomplete and complete duodenal obstruction. Methods: A retrospective, single-center study was performed using data from patients operated on for duodenal obstruction between 2004 and 2019. Prenatal ultrasound findings were obtained from maternal logbooks and directly from the investigating obstetricians. Postnatal data were obtained from electronic charts, including imaging, operative notes and follow-up. Results: A total of 33/64 parents of respective patients agreed to provide information on prenatal diagnostics. In total, 11/15 patients with complete duodenal obstruction and 0/18 patients with incomplete duodenal obstruction showed typical prenatal features. Prenatal diagnosis prompted immediate surgical treatment after birth. Conclusion: Prenatal diagnosis of congenital duodenal obstruction is only achievable in cases of complete congenital duodenal obstruction by sonographic detection of the pathognomonic double bubble sign. Patients with incomplete duodenal obstruction showed no sign of duodenal obstruction on prenatal scans and thus were diagnosed and treated later.

Prenatal detection of chromosomal abnormalities and copy number variants in fetuses with congenital gastrointestinal obstruction

Background

Congenital gastrointestinal obstruction (CGIO) mainly refers to the stenosis or atresia of any part from the esophagus to the anus and is one of the most common surgical causes in the neonatal period. The concept of genetic factors as an etiology of CGIO has been accepted, but investigations about CGIO have mainly focused on aneuploidy, and the focus has been on duodenal obstruction. The objective of this study was to evaluate the risk of chromosome aberrations (including numeric and structural aberrations) in different types of CGIO. A second objective was to assess the risk of abnormal CNVs detected by copy number variation sequencing (CNV-seq) in fetuses with different types of CGIO.

Methods

Data from pregnancies referred for invasive testing and CNV-seq due to sonographic diagnosis of fetal CGIO from 2015 to 2020 were obtained retrospectively from the computerized database. The rates of chromosome aberrations and abnormal CNV-seq findings for isolated CGIOs and complicated CGIOs and different types of CGIOs were calculated.

Results

Of the 240 fetuses with CGIO that underwent karyotyping, the detection rate of karyotype abnormalities in complicated CGIO was significantly higher than that of the isolated group (33.8% vs. 10.8%, p < 0.01). Ninety-three cases with normal karyotypes further underwent CNV-seq, and CNV-seq revealed an incremental diagnostic value of 9.7% over conventional karyotyping. In addition, the incremental diagnostic yield of CNV-seq analysis in complicated CGIOs (20%) was higher than that in isolated CGIOs (4.8%), and the highest prevalence of pathogenic CNVs/likely pathogenic CNVs was found in the duodenal stenosis/atresia group (17.5%), followed by the anorectal malformation group (15.4%). The 13q deletion, 10q26 deletion, 4q24 deletion, and 2p24 might be additional genetic etiologies of duodenal stenosis/atresia.

Conclusions

The risk of pathogenic chromosomal abnormalities and CNVs increased in the complicated CGIO group compared to that in the isolated CGIO group, especially when fetuses presented duodenal obstruction (DO) and anorectal malformation. CNV-seq was recommended to detect submicroscopic chromosomal aberrations for DO and anorectal malformation when the karyotype was normal. The relationship between genotypes and phenotypes needs to be explored in the future to facilitate prenatal diagnosis of fetal CGIO and yield new clues into their etiologies.

Chromosomal Abnormalities and Pregnancy Outcomes for Fetuses With Gastrointestinal Tract Obstructions

Fetal gastrointestinal tract obstruction (GITO) is the most frequently encountered gastrointestinal defect in the prenatal period. This study aimed to investigate the genetic disorders and pregnancy outcomes of fetal GITO. We reviewed data from 70 pregnancies that were referred for invasive prenatal testing because of fetal GITO. According to the level of obstruction, they were classified into esophageal atresia/stenosis, duodenal atresia/stenosis, jejunal or ileal atresia/stenosis, or anal atresia. Traditional karyotyping was performed on all the 70 pregnancies, and chromosomal microarray analysis (CMA) was performed on 32 of them in parallel. Traditional karyotyping revealed twelve (17.1%) chromosomal abnormalities, including 11 cases of trisomy 21 (Down syndrome), and one case of a supernumerary marker chromosome related to Cat eye syndrome. According to the absence or presence of other ultrasound anomalies, they were categorized into isolated GITO (n = 36) and non-isolated GITO (n = 34). The rate of chromosomal abnormalities in the non-isolated GITO pregnancies was significantly higher than that in the isolated GITO pregnancies (29.4 vs. 5.5%, p < 0.05); the survival rate in the isolated group was significantly higher than that in the non-isolated group (67.6 vs. 34.4%, p < 0.05). Among the 32 cases where CMA was performed, an additional one (3.1%) copy number variant with clinical significance was noted in a fetus with normal karyotype. The microduplication on 7q12 was considered to be the genetic etiology of duodenal stenosis, although it was inherited from a phenotypically normal mother. Our study supports the strong association between Down syndrome and fetal GITO, especially duodenal stenosis. Our findings suggested that the risk of chromosomal abnormalities was increased when GITO was accompanied by other ultrasound anomalies; thus, chromosomal abnormalities and fetal anatomy should be carefully evaluated for pregnancy management of fetal GITO.

Antenatal diagnosis of jejunal atresia by 3D HDlive ultrasound: Case report and literature review

Objectives

To report the case of a patient with a prenatal diagnosis of jejunal atresia and to review the literature regarding the results and prenatal diagnosis of this entity, implementing the use of non-conventional methods (3D ultrasound or magnetic resonance imaging).

Material and methods

Report of a case of an 18-year-old pregnant woman referred to the Maternal-Fetal Medicine, Genetics and Reproduction Unit of the Virgen del Rocío Hospital in Seville due to fetus with abdominal peristaltic cystic image, consistent with jejunal atresia, confirmed with 3D HDLive mode ultrasound. A bibliographic search was carried out in Medline/PubMed, Google Scholar and LILACS, restricting by type of language (English and Spanish) and date of publication (January 1995 to June 2020). Primary studies of reports and case series relating to the outcome and prenatal diagnosis of this pathology were included.

Results

The search identified 1,033 titles, of which four studies met the inclusion criteria, these being reports or case series. A total of twelve fetuses with a prenatal diagnosis of jejunal atresia detected with unconventional methods were reported. In all cases, the prenatal diagnosis was confirmed during the neonatal period, which required resection of the compromised segment; one of them died and two neonates developed short bowel syndrome because of a wide bowel resection. The postoperative course in the remaining cases was favorable.

Conclusion

The available literature on the prenatal diagnosis of jejunal atresia using non-conventional methods is scarce and is limited to case reports or case series. The literature reviewed suggests that, in the presence of intestinal dilation, 3D ultrasound and magnetic resonance imaging could be of some use in characterizing the atretic portion and establishing the differential diagnosis. More studies are required to evaluate the diagnostic utility of these two alternatives.

Fetal sigmoid colon mesentery made visible by routine ultrasound in the first and second trimester of pregnancy

BACKGROUND

Ultrasound is a routine procedure performed during pregnancy to monitor the status of the human fetus, including the development of the digestive tract. The aim of this publication was to determine the shape of the fetal sigmoid colon mesentery during the first and second trimester of pregnancy by means of ultrasound.

METHODS

The study was performed in 45 pregnant women (age: 36.4 years on average, range 25-45) during a routine ultrasound examination. The fetuses were between 12 and 22 weeks of pregnancy. The shape of the fetal sigmoid colon mesentery was analyzed.

RESULTS

We visualized the triangular shape of the mesentery in all 45 cases. A prevalence of scalene or isosceles acute triangles was found in both trimesters. At the 12-13 weeks we observed 5 different forms of mesenteric triangles - the scalene or isosceles acute triangles appeared at 33.3% and 28.6%, respectively. The obtuse scalene was present in 23.8 %. In the 2nd trimester (20-22 weeks) 4 types were found, among them 37.5 % acute scalene and 33.3 % acute isosceles.

CONCLUSIONS

The fetal sigmoid colon mesentery can be visualized from the 12th week of pregnancy. The triangular shape of the sigmoid colon mesentery is easy to follow during routine ultrasound examinations.

Microarray analysis in fetuses with duodenal obstruction: It is not just trisomy 21

OBJECTIVE

To explore the copy number variants (CNVs) in case of fetal duodenal obstruction (DO) and assess the associated prenatal findings and postnatal outcomes.

MATERIALS AND METHODS

This retrospective study reviewed 51 fetuses with DO and the findings of chromosomal microarray analysis (CMA) used as a first-tier test in our institution between January 2014 and May 2019.

RESULTS

The frequency of pathogenic aberrations in fetuses with DO was 15.7% (8/51), including 9.8% (5/51) pathogenic CNVs. Three fetuses with isolated DO each had a deletion on chromosome 13q, one fetus had duplication at 1q43q44, and one had microduplication at 17q12. No significant differences in pathogenic CNVs were observed between isolated DO and DO plus additional anomalies (4/42, 9.5% vs 1/9, 11.1%, P = .89). Of the 51 fetuses with DO, 11 pregnancies were terminated, and eight fetuses had chromosomal abnormalities; one pregnancy ended with intrauterine death, and there were 39 live births. Neonatal outcomes were available for 31 fetuses, and no neonatal deaths occurred after surgery.

CONCLUSIONS

Our cohort study demonstrated the value of CMA in fetuses with DO, suggesting that CNVs may underly genetic etiologies that should be considered in the diagnostic evaluation of DO. We think CMA should be recommended in case of DO.

Educational Case: Intrauterine Fetal Demise and Intestinal Atresia: An Autopsy Investigation

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.¹

Congenital duodenal obstruction in the UK: a population-based study

OBJECTIVE

Congenital duodenal obstruction (CDO) comprising duodenal atresia or stenosis is a rare congenital anomaly requiring surgical correction in early life. Identification of variation in surgical and postoperative practice in previous studies has been limited by small sample sizes. This study aimed to prospectively estimate the incidence of CDO in the UK, and report current management strategies and short-term outcomes.

DESIGN

Prospective population-based, observational study for 12 months from March 2016.

SETTING

Specialist neonatal surgical units in the UK.

MAIN OUTCOME MEASURES

Incidence of CDO, associated anomalies and short-term outcomes.

RESULTS

In total, 110 cases were identified and data forms were returned for 103 infants giving an estimated incidence of 1.22 cases per 10 000 (95% CI 1.01 to 1.49) live births. Overall, 59% of cases were suspected antenatally and associated anomalies were seen in 69%. Operative repair was carried out mostly by duodenoduodenostomy (76%) followed by duodenojejunostomy (15%). Postoperative feeding practice varied with 42% having a trans-anastomotic tube placed and 88% receiving parenteral nutrition. Re-operation rate related to the initial procedure was 3% within 28 days. Two infants died within 28 days of operation from unrelated causes.

CONCLUSION

This population-based study of CDO has shown that the majority of infants have associated anomalies. There is variation in postoperative feeding strategies which represent opportunities to explore the effects of these on outcome and potentially standardise approach. Short-term outcomes are generally good.

A new variant of type III jejunoileal atresia

Jejunoileal atresia (JIA) is a congenital defect that can result in significant loss of bowel length. The traditional classification of JIA was first proposed by Grosfeld and includes 4 subtypes. Among these, type IIIB, or apple-peel atresia, is characterized by a proximal atretic jejunum and a distal segment of spiraled bowel that terminates at the cecum. Owing to this anatomy, patients with type IIIB JIA are at increased risk for short bowel syndrome and intestinal failure. In this report, we described the case of a neonate with a prenatal diagnosis of JIA. At exploration, she was initially found to have a type IIIB atresia. However, instead of terminating at the cecum, the distal spiraled segment was followed by 75 cm of normal small bowel and mesentery. Surgical correction proceeded with minimal resection and primary anastomosis. She recovered well from this procedure, tolerated full enteral nutrition by mouth, and displayed good weight gain at outpatient follow-up. Owing to the unique anatomy of the gastrointestinal tract in this case report, we propose the addition of a new class of JIA, type IIIC, to better reflect its prognostication and surgical management.

Isolated Ascites in a Monochorionic Twin after Fetoscopic Laser Ablation Is Not Necessarily Secondary to Recurrence or Anaemia: Bowel Complications in Twin-to-Twin Transfusion Syndrome after Fetoscopic Laser Ablation

BACKGROUND/PURPOSE

We report a case study of jejunal atresia and the results of a systematic literature review of all reported cases of bowel complications occurring after fetoscopic laser ablation (FLA) for the treatment of twin-to-twin transfusion syndrome (TTTS).

METHODS

A systematic literature review was performed of bowel complications after FLA for TTTS according to PRISMA guidelines.

RESULTS

There are 11 published cases of small bowel atresia, 5 cases of necrotising enterocolitis (NEC), and 2 cases with foetal bowel perforations. Recipient twins were more likely to be affected by small bowel atresia (7 recipient and 4 donor cases) and NEC (3 recipient and 2 donor twins). Prenatal ultrasonographic abnormalities were demonstrated in 7 out of 9 cases with bowel atresia and in both cases of bowel perforation. The overall survival rate for neonates with bowel complications after FLA is 72%, but is much lower for co-twins at 22%. The survival rates for jejunoileal atresia and NEC are 91 and 40%, respectively.

CONCLUSIONS

It is uncertain as to whether these bowel anomalies are due to bowel ischaemia associated with TTTS, the treatment with FLA, or a combination of both. Cases with prenatal abdominal ultrasonographic abnormalities after FLA should have close prenatal and postnatal assessment to detect bowel complications.

A Simple and Easy Technique for Imaging the Fetal Esophagus in the First, Second, and Third Trimesters Using the Transverse Section of the Esophagus in the Area Behind the Heart as a Reference Point

OBJECTIVE

To describe and evaluate a simple technique of imaging the fetal esophagus, using the echogenic transverse section of the esophagus in the area behind the heart as a reference point, in all the 3 trimesters of pregnancy.

METHOD

This was a prospective cross-sectional study of ultrasound imaging of the esophagus in 2 groups of patients: the first group comprised women at 18 to 30 weeks' gestation (208 fetuses); the second group comprised women at 11 to 14 weeks' gestation (102 fetuses). Using a 3- to 5-MHz curvilinear transducer, the transverse section of the collapsed esophagus was imaged in the area behind the heart. The probe was rotated 90 degrees to identify the longitudinal section of the esophagus which was then traced along its entire length.

RESULT

This study shows that the collapsed, echogenic, transverse section of the esophagus was persistently seen in the area behind the heart, in more than 99% of fetuses in both the groups. It was a useful starting point to image the longitudinal section of the esophagus in both the groups, particularly in the 18 - 30 week group. Using this technique, the entire length of the esophagus could be traced in 92.3% of 18 - 30 week fetuses and 88.23% of the 11 - 14 week fetuses.

CONCLUSION

A collapsed transverse section of the esophagus was persistently and easily seen as a bright echogenic structure in the area behind the heart in more than 99% of fetuses in all 3 trimesters (in both the groups) and, therefore, was an ideal starting point to begin tracing the esophagus in its longitudinal axis.

Evaluation of pre- and postnatally diagnosed gastrointestinal tract obstructions

Purpose: Signs of congenital obstruction of the gastrointestinal tract (GIT) organs may present on prenatal ultrasonography. Prenatal detection is influenced by several factors, including obstruction site, lesion degree (partial or complete), the occurrence of associated malformations, and gestational week at screening. Here, we aimed to evaluate the success of prenatal diagnosis of GIT obstructions in a tertiary center in Turkey. Materials and methods: The study included 34 prenatally and 22 postnatally diagnosed babies with different GIT malformations. GIT obstructions were divided into five groups according to the level of obstruction (A. esophagus, B. stomach and proximal duodenum, C. small intestine, D. large intestine, E. multiple obstructions). Results: The prenatal detection rate among all cases was 60.7%. The associated structural malformation and aneuploidy rates were 21.4 and 5.4%, respectively. Twelve neonates died within the first day after birth due to various reasons. The remaining 43 babies underwent surgery at different times according to their clinical conditions. The mean time between birth and surgery was 4.5 days (range, 1-56 days). There were 12 postoperative deaths due to various complications, and one case died at 2 years of age. Overall, 31 of the 56 (55.4%) babies were alive during the follow-up period. The successful prenatal diagnosis rates were 57.2, 85.8, 75, 25, and 80% in groups A, B, C, D, and E, respectively. The median birth weight increased significantly in groups A through D (p = .04). However, there were no intergroup differences in the Apgar scores, associated abnormality rates, time to surgery, and number of babies operated. Conclusions: These findings demonstrate the importance of prenatal ultrasonography and success of prenatal detection especially for upper GIT abnormalities. Although there are some prenatal signs of GIT obstructions, such as double bubble, polyhydramnios, enlarged bowel, and failure to visualize the stomach, early prenatal diagnosis is difficult and can be delayed, resulting in the detection of GIT obstruction after birth. When suspecting GIT obstruction, clinicians should evaluate the fetal anatomy carefully and be aware of associated chromosomal abnormalities.

Prenatal diagnosis and outcome of fetal gastrointestinal obstruction

INTRODUCTION

The purpose of this study was to evaluate the accuracy of prenatal diagnosis for fetuses with gastrointestinal (GI) obstruction with correlation to postnatal outcomes.

METHODS

Fetuses diagnosed with GI obstruction (excluding esophageal and duodenal) were reviewed for those evaluated between 2006 and 2016. Prenatal diagnosis and imaging studies were compared to postnatal findings. Outcomes evaluated included diagnostic accuracy, rate of other anomalies, neonatal length of stay, incidence of short bowel syndrome, and discharge with TPN or gastrostomy.

RESULTS

Forty-eight patients were diagnosed prenatally with obstruction. Six patients were excluded owing to incomplete records and follow-up. Twelve fetuses were diagnosed with ultrasound alone, and thirty-four with ultrasound and MRI. A diagnosis of obstruction was accurate in 88.1% (n=37/42) with a positive predictive value of 91.3%, while US with MRI had an accuracy of 84.4%. Associated anomalies were highest among fetuses with anorectal obstruction (90.1%), compared to large (50%) or small bowel obstruction (28%). Survival rate was lowest for anorectal obstruction (54.5%), compared to large or small bowel obstruction (100% for both).

CONCLUSION

Fetal MRI is an accurate modality in the diagnosis of fetal GI obstruction and can complement findings characterized by ultrasound. Fetuses with anorectal obstruction have a higher rate of associated anomalies and the lowest survival.

LEVEL OF EVIDENCE

IIb.

Prenatal magnetic resonance and ultrasonographic findings in small-bowel obstruction: imaging clues and postnatal outcomes

BACKGROUND

Prenatal small-bowel obstruction can result from single or multiple atresias, and it can be an isolated abnormality or part of a syndrome. It is sometimes the first manifestation of cystic fibrosis. Accurate prediction of the level of obstruction and length of bowel affected can be difficult, presenting a challenge for counseling families and planning perinatal management.

OBJECTIVE

To review the prenatal US and MRI findings of small-bowel obstruction and to assess whether fetal MRI adds information that could improve prenatal counseling and perinatal management.

MATERIALS AND METHODS

We retrospectively reviewed 12 prenatally diagnosed cases of small-bowel obstruction evaluated by both US and MRI from 2005 to 2015. We analyzed gestational age at evaluation, US and MRI findings, gestational age at delivery and postnatal outcomes.

RESULTS

The final diagnoses were jejunal atresia (7), ileal atresia (1), cystic fibrosis (3) and combined jejunal and anal atresia (1). Four of the eight with jejunal atresia were found to have multiple small-bowel atresias. Prenatal perforation was noted in three. We identified a trend of increasing complexity of bowel contents corresponding to progressively distal level of obstruction, as indicated by increasing US echogenicity and high T1 signal on MRI. Seven cases of jejunal atresia and one case of ileal atresia demonstrated small ascending, transverse and descending colon (microcolon) with filling of a normal-diameter rectum. In contrast, all three fetuses with cystic fibrosis and the fetus with jejunal-anal atresia demonstrated microcolon as well as abnormal paucity or absence of rectal meconium. Polyhydramnios was present in nine. Eight were delivered prematurely, of whom seven had polyhydramnios. The fetus with jejunal and anal atresia died in utero. Postnatally, three had short gut syndrome, all resulting from multiple jejunal atresias; these three were among a subset of four fetuses whose bowel diameter measured more than 3 cm. Eight infants had no further gastrointestinal complications. The presence of multiple atresias was not predicted by prenatal US or MRI.

CONCLUSION

MR provides useful additional information regarding meconium distribution in the small bowel, which helps to clarify the level of obstruction. MR was additionally useful in the assessment of colon and rectal contents, serving as a fetal enema. Abnormally diminished meconium in the rectum suggests cystic fibrosis or combined small-bowel and colonic obstruction, information that is useful in counseling and preparing for postnatal care.

Duodenal atresia with apple-peel configuration of the ileum and absent superior mesenteric artery

Background

Embryologically, duodenal atresia results from inadequate recanalisation and proliferation of gut epithelius in the 6th week of gestation, while apple-pee atresia of small bowel is a consequence of a vascular accident in subsequent embryonic development, and the two are rather rarely manifested as a joint clinical entity.

Case presentation

We present here a 29 week preterm boy admitted to the intensive care unit due to breathing difficulties and low birthweight. Following clinical, radiographic and ultrasound examination, he was diagnosed with duodenal obstruction and subjected to surgical treatment.

The exploration of abdominal cavity verified duodenal atresia in the second portion with the absence of third and fourth portions of duodenum, superior mesenteric artery, as well as apple-peel atresia of jejunum. Resection of the apple-peel segment of jejunum was done and the continuity of digestive tube was established by the end-to-end duodeno-ileal anastomosis.

Conslusion

This rare case of ours questions the embryology of duodenal atresia suggesting that a mesenteric vascular disruption phenomenon in subsequent embryonic life might be the aetiological factor.

Association Between Prenatal Sonographic Findings of Duodenal Obstruction and Adverse Outcomes

OBJECTIVES

The purpose of this study was to evaluate the association of prenatal sonographic findings with adverse outcomes and the causes of duodenal obstruction.

METHODS

A total of 59 cases of congenital duodenal obstruction were included in this study. The sonographic findings, including the degree of duodenal dilatation, polyhydramnios, and their change over gestation, were investigated. Adverse outcomes were defined as fetal death in utero, postnatal death, and gastrointestinal complications requiring readmission or reoperation during the follow-up period. The cause of duodenal obstruction was also assessed.

RESULTS

Among the patients studied, 2 (3.4%) had fetal death in utero and 2 (3.5%) had postnatal death. Gastrointestinal complications requiring readmission or reoperation occurred in 10.9%. In the cases with or without adverse outcomes, no significant differences were observed in the prenatal sonographic findings: maximum duodenal dilatation, mean amniotic fluid index, and the changes in these parameters with advancing gestation. The cases with adverse outcomes were associated with a younger gestational age at delivery compared to the cases without adverse outcomes. Notably, the degree of duodenal dilatation and amniotic fluid volume were greater in duodenal atresia than in other causes of obstruction, including duodenal stenosis, a duodenal web, and an annular pancreas. In the study population, the overall postoperative survival rate was 98.2%.

CONCLUSIONS

Prenatal sonographic findings of duodenal obstruction were not associated with adverse outcomes; however, they may be helpful for differentiating the cause of duodenal obstruction.

Prenatal diagnosis of gastric and small bowel atresia: a case series and review of the literature

OBJECTIVE

To describe seven cases of gastrointestinal tract (GIT) obstructions and to report a skewed review of the literature.

METHODS

We performed a search of our permanent perinatal database about cases with prenatal ultrasound and MRI diagnosis of gastrointestinal tract obstructions between 2006 and 2013. All cases were followed until hospital discharge and pre-natal diagnosis were confirmed by fetal MRI, postnatal imaging and/or intra-operative findings. Maternal age, parity, gestational age at diagnosis, ultrasound findings, gestational age at delivery, Apgar scores at 1 and 5 min and postnatal outcome have been recorded.

RESULTS

We identified seven cases of gastric and small bowel atresia. Karyotype was normal in six cases and abnormal in one co-twin [46,XY dup (20) (qq13.1q13.3)dn] of a dichorionic-diamniotic pregnancy. The mean ± SD for maternal age, gestational age at diagnosis, gestational at delivery, birth weight and Apgar scores at 1 and 5 min were 30.8 ± 4.8 years, 29.8 ± 3.7 weeks, 2507.5 ± 727.5 g and 5.6 ± 2.1, 7.6 ± 1.6, respectively. All fetuses' undergone surgical procedures in the postnatal period and all of them were discharged live from the hospital.

CONCLUSION

Prompted antenatal detection of gastrointestinal tract obstruction using ultrasound proved to be diagnostic in all cases. Fetal MRI aid was a useful complementary diagnostic investigation. Correct pre-natal diagnosis allows adequate counseling, delivery planning and management care by a multidisciplinary team.

Prenatal Imaging of the Gastrointestinal Tract with Postnatal Imaging Correlation

Prenatal detection of a wide variety of anomalies and masses of the gastrointestinal tract is now possible. Prenatal imaging with ultrasonography and in selected cases magnetic resonance imaging provides invaluable information to the referring obstetrician, the maternal fetal medicine specialist, the neonatologist and pediatrician who will care for the child after birth, the surgeons and pediatric specialists who will repair or manage a prenatally detected anomaly, and of course to the parents, allowing them to prepare psychologically and financially for the specific interventions that may be needed for their child. Additional screening for associated anomalies can take place, route of delivery can be decided, and arrangements for delivery in an appropriate setting can be made. Prenatal detection also allows for consideration for pregnancy termination. This article will give a broad overview of anomalies of the gastrointestinal tract that can be detected prenatally and their imaging appearance postnatally.

Accuracy of prenatal ultrasound in detecting jejunal and ileal atresia: systematic review and meta-analysis

OBJECTIVE

The accuracy of prenatal ultrasound examination in detecting jejunal and ileal atresia has been reported in the literature to be highly variable, at 25-90%. The aim of this systematic review was to evaluate the accuracy of prenatal ultrasound in detecting non-duodenal small bowel atresia (ND-SBA).

METHODS

MEDLINE, EMBASE and The Cochrane Library, including The Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE) and The Cochrane Central Register of Controlled Trials (CENTRAL), were searched electronically. The overall detection rate of jejunal or ileal atresia using ultrasound was reported. The accuracy of using polyhydramnios and dilated loops of bowel as diagnostic signs was also explored.

RESULTS

Sixteen studies involving 640 fetuses were included in this review. The detection rate of ND-SBA by prenatal ultrasound was highly variable, with values ranging from 10 to 100%, with an overall prediction of 50.6% (95% CI, 38.0-63.2%). When analyzed separately, the detection rates of jejunal and ileal atresia were 66.3%, (95% CI, 33.9-91.8%) and 25.9% (95% CI, 4.0-58.0%), respectively. Both dilated loops of bowel and polyhydramnios as diagnostic signs for ND-SBA provided a low overall detection rate.

CONCLUSIONS

The diagnostic performance of prenatal ultrasound in identifying ND-SBA is extremely variable. Large studies are needed in order to identify objective and combined criteria for the diagnosis of these anomalies.

Diagnostic Accuracy of Prenatal Ultrasound in Identifying Jejunal and Ileal Atresia

Introduction: Small bowel atresia (SBA) is one of the most common causes of congenital intestinal obstruction. However, the accuracy of prenatal ultrasound in diagnosing this condition has not been entirely ascertained. The aim of this study was to analyse the predictive accuracy of ultrasound in detecting SBA prenatally. Methodology: Retrospective study of all cases with prenatal suspicion or postnatal confirmed SBA seen in a tertiary fetal medicine and pediatric surgery units from 2007 to 2013. Cases with duodenal atresia were excluded from the study. The predictive accuracy of ultrasound and different ultrasound signs, alone and in combination, was calculated. Results: 65 fetuses with prenatal suspicion or postnatal confirmed SBA were enrolled. 58 cases had full data and were included in the analysis. Predictive accuracy of ultrasound in detecting the presence of SBA was poor, with a sensitivity of 50% (95% CI 26.0-74.0) and a specificity of 70.59% (95% CI 52.5-84.9). The presence of both bowel dilatation ≥17 mm and polyhydramnios after 32 weeks of gestation slightly increased sensitivity (66.67%, 95% CI 34.9-90.1) and specificity (80.00%, 95% CI 44.4-97.5). Conclusions: In case of suspicion of SBA before the 3rd trimester, an ultrasound after 32 weeks should be performed to confirm the presence of both polyhydramnios and bowel dilatation >17 mm.

Population-based study of esophageal and small intestinal atresia/stenosis

BACKGROUND

The aim of this study was to describe the prevalence of esophageal atresia/stenosis and small intestinal atresia/stenosis in Nagano, Japan, together with associated anomalies, prenatal diagnosis and survival.

METHODS

A population-based cohort study of the prevalence of esophageal atresia/stenosis and small intestinal atresia/stenosis was conducted in Nagano in January 1993-December 2011. The Mann-Whitney test, χ(2) test and Kruskal-Wallis test were used to compare variables. P < 0.05 was considered statistically significant.

RESULTS

In total, 74 cases of esophageal atresia/stenosis and 87 cases of small intestinal atresia/stenosis (31 duodenal, 56 jejuno-ileal) were identified. Prevalences were 1.97 for esophageal atresia/stenosis and 2.23 for small intestinal atresia/stenosis (0.83 for duodenal atresia/stenosis and 1.49 for jejuno-ileal atresia/stenosis) per 10,000 births, respectively. The prevalence of esophageal atresia/stenosis increased significantly from 1993-2001 to 2002-2011 (relative risk [RR], 1.6), as did the prevalences of duodenal atresia/stenosis (RR, 2.2) and jejuno-ileal atresia/stenosis (RR, 3.1). Chromosomal anomalies, particularly trisomy 21, were seen significantly more often in association with duodenal atresia/stenosis (55%) than with esophageal atresia/stenosis (28%, P < 0.01) or jejuno-ileal atresia/stenosis (2%, P < 0.01). The proportion of patients associated with prenatally diagnosed chromosomal anomaly was higher compared to postnatal diagnosis (P < 0.01) in the esophageal atresia/stenosis group.

CONCLUSION

The prevalence of esophageal and small intestinal atresia/stenosis increased significantly from 1993-2001 to 2002-2011. Prenatally diagnosed esophageal atresia/stenosis is associated with multiple anomalies, particularly chromosomal anomalies, compared to other small intestine atresia/stenosis.

Colonic atresia and anorectal malformation in a Haitian patient: a case study of rare diseases

INTRODUCTION

Colonic atresia and anorectal malformation are rare congenital anomalies individually. Few reports of the conditions combined in a single patient have been published in the literature. Neither colonic atresia, anorectal malformation or a combination of the disorders has previously been reported in the Haitian population.

CASE PRESENTATION

A 5-day-old female presented with feculent emesis, failure to pass stool since birth and an imperforate and stenotic anus. Exploratory laparotomy revealed colorectal atresia distal to a malformed cecum and a Wingspread low subtype anorectal malformation without any associated urogenital fistulae. Temporizing percutaneous ileal drainage was followed by second-stage anal perforation and dilation, ileal J-pouch and pull through.

DISCUSSION

This is the first reported case of colonic atresia, anorectal malformation or the combination of the disorders among the Haitian population and one of only a handful of such cases reported worldwide. Although vascular accidents in utero have been implicated as the etiology of colonic atresia, simultaneous presence of anorectal malformation suggests a multifactorial cause. Investigation for multisystem abnormalities is warranted. Two-staged operative correction is considered the best treatment; however, long-term postoperative outcomes are uncertain.

CONCLUSION

The coexistence of colonic atresia and anorectal malformation is a very rare occurrence and presents unique clinical and operative challenges. Investigation for additional congenital abnormalities is appropriate, and although two-stage operative correction is considered the best treatment, long-term outcomes are uncertain.

Prevalence of esophageal atresia among 18 international birth defects surveillance programs

BACKGROUND

The prevalence of esophageal atresia (EA) has been shown to vary across different geographical settings. Investigation of geographical differences may provide an insight into the underlying etiology of EA.

METHODS

The study population comprised infants diagnosed with EA during 1998 to 2007 from 18 of the 46 birth defects surveillance programs, members of the International Clearinghouse for Birth Defects Surveillance and Research. Total prevalence per 10,000 births for EA was defined as the total number of cases in live births, stillbirths, and elective termination of pregnancy for fetal anomaly (ETOPFA) divided by the total number of all births in the population.

RESULTS

Among the participating programs, a total of 2943 cases of EA were diagnosed with an average prevalence of 2.44 (95% confidence interval [CI], 2.35-2.53) per 10,000 births, ranging between 1.77 and 3.68 per 10,000 births. Of all infants diagnosed with EA, 2761 (93.8%) were live births, 82 (2.8%) stillbirths, 89 (3.0%) ETOPFA, and 11 (0.4%) had unknown outcomes. The majority of cases (2020, 68.6%), had a reported EA with fistula, 749 (25.5%) were without fistula, and 174 (5.9%) were registered with an unspecified code.

CONCLUSIONS

On average, EA affected 1 in 4099 births (95% CI, 1 in 3954-4251 births) with prevalence varying across different geographical settings, but relatively consistent over time and comparable between surveillance programs. Findings suggest that differences in the prevalence observed among programs are likely to be attributable to variability in population ethnic compositions or issues in reporting or registration procedures of EA, rather than a real risk occurrence difference. Birth Defects Research (Part A), 2012.

Fetal MR in the evaluation of pulmonary and digestive system pathology

BACKGROUND

Prenatal awareness of an anomaly ensures better management of the pregnant patient, enables medical teams and parents to prepare for the delivery, and is very useful for making decisions about postnatal treatment. Congenital malformations of the thorax, abdomen, and gastrointestinal tract are common. As various organs can be affected, accurate location and morphological characterization are important for accurate diagnosis.

METHODS

Magnetic resonance imaging (MRI) enables excellent discrimination among tissues, making it a useful adjunct to ultrasonography (US) in the study of fetal morphology and pathology.

RESULTS

MRI is most useful when US has detected or suspected anomalies, and more anomalies are detected when MRI and US findings are assessed together.

CONCLUSION

We describe the normal appearance of fetal thoracic, abdominal, and gastrointestinal structures on MRI, and we discuss the most common anomalies involving these structures and the role of MRI in their study.

TEACHING POINTS

• To learn about the normal anatomy of the fetal chest, abdomen, and GI tract on MRI. • To recognize the MR appearance of congenital anomalies of the lungs and the digestive system. • To understand the value of MRI when compared to US in assessing fetal anomalies.

Omphalocele: comparison of outcome following prenatal or postnatal diagnosis

OBJECTIVES

To assess the impact of prenatal compared with postnatal diagnosis on outcome for liveborn infants with an isolated or with a non-isolated omphalocele.

METHODS

This was a retrospective analysis of 101 prenatally and 45 postnatally diagnosed cases of omphalocele. Cases were collected from the ultrasound database of the Division of Obstetrics and Prenatal Medicine and the patient database of the Department of Pediatric Surgery.

RESULTS

Following confirmation at delivery or autopsy, prenatally diagnosed omphaloceles included 21 isolated cases, 44 non-isolated cases with a normal karyotype and 36 non-isolated cases with an abnormal karyotype. Of the prenatally diagnosed apparently isolated cases (n = 31), 12 (39%; 95% CI, 22-58%) revealed associated anomalies after delivery. Liveborn infants with an isolated omphalocele had significantly worse short-term morbidity following prenatal diagnosis (n = 14) compared with diagnosis at birth (n = 29), having a lower gestational age at delivery, lower Apgar scores, longer duration of ventilation and parenteral nutrition, more readmissions and a longer hospital stay. The prenatally diagnosed subset contained more infants with a giant omphalocele (9/14 vs. 3/29, P = 0.001) and liver herniation (8/14 vs. 6/29, P = 0.02). The outcome of liveborn infants with a non-isolated omphalocele diagnosed prenatally (n = 17) was not different from that of those diagnosed at birth (n = 16), except for a greater need for ventilation and parenteral nutrition in the prenatal subset.

CONCLUSION

When counseling patients with a prenatal diagnosis of isolated omphalocele, it is important to remember that over one third could turn out to have associated anomalies. Liveborn infants with an isolated omphalocele detected prenatally have worse short-term morbidity than do cases detected at birth. Those with non-isolated omphaloceles detected prenatally have an increased need for ventilation and parenteral nutrition compared with those detected at birth.

Commonly encountered surgical problems in the fetus and neonate

Neonatal surgical care requires a current understanding of pre- and postnatal intervention for a myriad of congenital anomalies. This article includes an update of the recent information on commonly encountered fetal and neonatal surgical problems, highlighting specific areas of controversy and challenges in diagnosis. The authors hope that this article is useful for trainees and practitioners involved in any aspect of fetal and neonatal care.

Congenital gastrointestinal defects in Down syndrome: a report from the Atlanta and National Down Syndrome Projects

We report Down syndrome (DS)-associated congenital gastrointestinal (GI) defects identified during a 15 year, population-based study of the etiology and phenotypic consequences of trisomy 21. Between 1989 and 2004, six sites collected DNA, clinical and epidemiological information on live-born infants with standard trisomy 21 and their parents. We used chi-squared test and logistic regression to explore relationships between congenital GI defects and infant sex, race, maternal age, origin of the extra chromosome 21, and presence of a congenital heart defect. Congenital GI defects were present in 6.7% of 1892 eligible infants in this large, ethnically diverse, population-based study of DS. Defects included esophageal atresia/tracheoesophageal fistula (0.4%), pyloric stenosis (0.3%), duodenal stenosis/atresia (3.9%), Hirschsprung disease (0.8%), and anal stenosis/atresia (1.0%). We found no statistically significant associations between these defects and the factors examined. Although not significant, esophageal atresia was observed more often in infants of younger mothers and Hispanics, Hirschsprung disease was more frequent in males and in infants of younger mothers and blacks, and anal stenosis/atresia was found more often among females and Asians.

Isolated or non-isolated duodenal obstruction: perinatal outcome following prenatal or postnatal diagnosis

OBJECTIVES

To determine whether the pre- or postnatal diagnosis of either isolated or non-isolated duodenal obstruction (DO) is associated with different outcomes.

METHODS

A single-center retrospective analysis was carried out of 91 cases diagnosed with a DO between January 1991 and June 2003. Data on the diagnosis, treatment and outcomes of the cases were gathered, and differences between the groups were analyzed.

RESULTS

Twenty-eight cases of DO were diagnosed before and 63 after birth. Of 15 presumed isolated cases in the prenatally diagnosed group, four revealed associated or chromosomal anomalies after birth. The types of obstruction present were significantly different between the prenatally (n = 11) and postnatally (n = 27) detected subsets of isolated DO. The prenatally detected subset displayed a lower median gestational age at delivery, lower median birth weight and a higher prematurity rate (8/11 vs. 8/27). The diagnosis of DO occurred significantly later in the postnatally detected subset than the postnatal confirmation of the diagnosis in the prenatally detected cases. In the non-isolated cases of DO, no difference was found in the type of chromosomal or associated anomaly or the type of obstruction between the prenatally detected (n = 17) and postnatally detected subsets (n = 36). Trisomy 21 was present in 7/17 (41%) vs. 22/36 (61%) cases, respectively. Two terminations and three intrauterine deaths occurred in the prenatal non-isolated subset. The liveborn infants from the prenatally detected non-isolated subset (n = 12) showed a significantly higher prematurity rate (9/12 vs.14/36), lower median birth weight and earlier confirmation of diagnosis after delivery. After surgery, outcome was similar between both subsets of isolated and non-isolated DO. All the infants with an isolated DO survived. Neonatal death occurred in three prenatally and five postnatally diagnosed cases with non-isolated DO.

CONCLUSIONS

The outcome of prenatally and postnatally diagnosed DO is not essentially different despite more prematurity and a lower birth weight in the former. Of the prenatally detected cases of DO assumed to be isolated, 25% revealed additional chromosomal or associated anomalies after delivery, which influenced outcome.

Open vs laparoscopic repair of congenital duodenal obstructions: a concurrent series

OBJECTIVE

The advantages of using laparoscopy for repair of congenital duodenal obstructions (CDO) are unclear because of scant data about complications and outcomes. Nitinol U-clips (Medtronic Surgical, Minneapolis, Minn) were developed to assist in the creation of vascular anastomoses in small vessels. Because of their ability to approximate tissue tightly with little tissue damage, we have begun to use these U-clips for laparoscopic repair of CDO. In this report, we investigate the impact of laparoscopic U-clip repair of CDO compared to the traditional open repair.

METHODS

With institutional review board approval, a retrospective analysis of all patients undergoing repair of CDO from January 2003 to July 2007 was performed. During this study period, patients who underwent open repair of CDO (group 1) were compared with patients that underwent laparoscopic repair using the U-clip technique (group 2).

RESULTS

Twenty-nine patients underwent repair of CDO. Fourteen patients (11 atresia, 3 stenosis) were in group 1 and 15 patients (11 atresia, 4 stenosis) in group 2. A female sex bias existed in group 1 (female-male [9:5]) compared to group 2 (female-male [7:8]). There was no difference in birth weight, age at operation, chromosomal anomalies, or congenital heart disease between the groups. There were no duodenal anastomotic leaks in either group. Operative times were similar between groups (96 vs 126 minutes; P = .06). The length of postoperative hospitalization (20.1 vs 12.9 days; P = .01), time to initial feeding (11.3 vs 5.4 days; P = .002), and time to full oral intake (16.9 vs 9 days; P = .007) were all statistically shorter in group 2.

CONCLUSIONS

The laparoscopic approach to CDO repair using U-clips is safe and efficacious. In addition, patients undergoing laparoscopic repair of CDO had a shorter length of hospitalization and more rapid advancement to full feeding compared to babies undergoing the open approach. We feel that in the hands of experienced laparoscopic surgeons, the preferred technique for correction of CDO will become the laparoscopic U-clip repair.

Small intestinal atresia in a defined population: occurrence, prenatal diagnosis and survival

OBJECTIVE

To describe the prevalence, associated anomalies, prenatal diagnosis, and survival of cases of congenital small intestinal atresia (SIA).

METHOD

Data were extracted from the Northern Congenital Abnormality Survey (NorCAS) for cases delivered during 1991 to 2001.

RESULTS

A total of 99 cases of SIA were notified from 372 717 registered births. Twenty-five (25.8%) SIA cases were associated with a chromosomal anomaly. Of the 72 SIA cases with normal karyotype, 18 (25%) were associated with other structural anomalies. The total prevalence for all SIA cases over the 11 years was 2.66 per 10 000 registered births (95% CI 2.13, 3.18), and the livebirth prevalence was 2.37 per 10 000 livebirths (95% CI 1.88, 2.87). For jejunoileal atresia, the total prevalence increased from 0.54 per 10 000 births during 1991-1995 to 1.11 per 10 000 births during 1996-2001, and livebirth prevalence increased from 0.49 to 1.06 per 10 000 livebirths. The more proximal the lesion the prenatal diagnosis sensitivity was slightly better with 19 (44.2%) cases of duodenal atresia and 3 (42.8%) cases of jejunal atresia diagnosed prenatally by routine ultrasonography.

CONCLUSION

This population-based study of SIA has confirmed several previous findings but, by considering subtypes separately, it also suggests a trend towards an increase in the prevalence of jejunoileal atresia (JIA).

Descriptive epidemiology of Cornelia de Lange syndrome in Europe

Cornelia de Lange syndrome (CdLS) is a multiple congenital anomaly/mental retardation syndrome consisting of characteristic dysmorphic features, microcephaly, hypertrichosis, upper limb defects, growth retardation, developmental delay, and a variety of associated malformations. We present a population-based epidemiological study of the classical form of CdLS. The data were extracted from the database of European Surveillance of Congenital Anomalies (EUROCAT) database, a European network of birth defect registries which follow a standard methodology. Based on 23 years of epidemiologic monitoring (8,558,346 births in the 1980-2002 period), we found the prevalence of the classical form of CdLS to be 1.24/100,000 births or 1:81,000 births and estimated the overall CdLS prevalence at 1.6-2.2/100,000. Live born children accounted for 91.5% (97/106) of cases, fetal deaths 2.8% (3/106), and terminations of pregnancy following prenatal diagnosis 5.7% (6/106). The most frequent associated congenital malformations were limb defects (73.1%), congenital heart defects (45.6%), central nervous system malformations (40.2%), and cleft palate (21.7%). In the last 11 years, as much as 68% of cases with major malformations were not detected by routine prenatal US. Live born infants with CdLS have a high first week survival (91.4%). All patients were sporadic. Maternal and paternal age did not seem to be risk factors for CdLS. Almost 70% of patients, born after the 37th week of gestation, weighed <or=2,500 g. Low birth weight correlated with a more severe phenotype. Severe limb anomalies were significantly more often present in males.

Gastrointestinal malformations: impact of prenatal diagnosis on gestational age at birth

The aim of the study was to analyse the degree to which gestational age (GA) has been shortened due to prenatal diagnosis of gastrointestinal malformations (GIM). The data source for the study was 14 population-based registries of congenital malformations (EUROCAT). All liveborn infants with GIMs and without chromosomal anomalies, born 1997-2002, were included. The 14 registries identified 1047 liveborn infants with one or more GIMs (oesophageal atresia, duodenal atresia, omphalocele, gastroschisis and diaphragmatic hernia). Median GA at birth was lower in prenatally diagnosed cases for all five malformations, although not statistically significant for gastroschisis. There was little difference in median birthweight by GA for the pre- and postnatally diagnosed infants. The difference in GA at birth between prenatally and postnatally diagnosed infants with GIMs is enough to increase the risk of mortality for the prenatally diagnosed infants. Clinicians need to balance the risk of early delivery against the benefits of clinical convenience when making case management decisions after prenatal diagnosis. Very few studies have been able to show benefits of prenatal diagnosis of congenital malformations for liveborn infants. This may be because the benefits of prenatal diagnosis are outweighed by the problems arising from a lower GA at birth.

[Congenital anatomic gastrointestinal obstruction: prenatal diagnosis, morbidity and mortality]

OBJECTIVES

To describe the morbidity and mortality associated with congenital gastrointestinal obstruction, assess the usefulness of prenatal diagnosis, and analyze the results in relation to the site of obstruction.

PATIENTS AND METHODS

We performed a retrospective case series study of 148 patients in a 13-year period (1990-2003). Sites of obstruction was classified into three groups: I) gastric, duodenal or jejunal; II) ileal or colonic; III) anorectal.

RESULTS

There were 65 patients in group I, 38 in group II and 45 in group III. Surgery was performed in 137 patients. Trisomy was diagnosed in 15 patients, polymalformation syndrome in 16 patients, and cystic fibrosis in seven patients. More than one site of intestinal obstruction was found in 22 patients (15 %). Morbidity consisted of nosocomial sepsis in 32 %, necrotizing enterocolitis in 7 %, and short gut in 3.4 %. Prematurity (48 %) was associated with higher morbidity and mortality. Overall mortality was 14.2 %, mainly associated with other malformations and extraintestinal problems. When patients with other extraintestinal malformations were excluded, the highest mortality was found in group II (OR: 12.19; CI: 2.4-76.2). The overall sensitivity of prenatal diagnosis was 0.44 and the mean gestational age at diagnosis was 31.6 weeks (SD 5.2). According to the site of obstruction, sensitivity was 0.77 in group I, 0.39 in group II and 0.04 in group III. Prenatal diagnosis did not alter prognosis.

CONCLUSIONS

Morbidity and mortality were strongly influenced by extraintestinal problems. The most severe intestinal complications were midgut volvulus and necrotizing enterocolitis. Prenatal diagnosis was late and showed good sensitivity only in group I.

Contribution of fetal magnetic resonance imaging and amniotic fluid digestive enzyme assays to the evaluation of gastrointestinal tract abnormalities

OBJECTIVE

To analyze the contribution of fetal magnetic resonance imaging (MRI) and amniotic fluid digestive enzyme (AFDE) assays to the evaluation of gastrointestinal tract abnormalities.

METHODS

This was a prospective study involving 24 fetuses suspected of having gastrointestinal tract abnormalities on ultrasound examination. MRI was used to analyze the location of the obstruction, the visibility of the small bowel not involved in the obstruction, and the visibility and size of the colon and rectum. Abnormalities were further evaluated by AFDE assays. The final diagnosis was based on postnatal or fetopathological examination.

RESULTS

In duodenojejunal obstructions, MRI (6/6) and AFDE assays (4/4) correctly identified the level of obstruction, but were less accurate for small bowel obstructions (MRI, 10/11; AFDE assays, 7/11). The small bowel not involved in the obstruction was correctly evaluated by MRI as being viable in six cases and as abnormal in eight cases (multiple obstructions or necrosis). However, it was thought antenatally to be abnormal by MRI in four cases in which it was found to be normal on postnatal findings. Three cases in which the colon was found to have abnormal echogenicity were considered normal both by MRI and AFDE assay, in agreement with postnatal findings. Two cases of microcolon-megacystis-intestinal hypoperistalsis syndrome (MMIHS) were diagnosed both by MRI and AFDE assay. Of the three anorectal malformations, two were overlooked by ultrasonography and one by MRI. MRI also overlooked 2/3 associated rectourethral fistulas.

CONCLUSION

MRI and enzyme analysis are good complementary tools to ultrasonography for identifying the level of gastrointestinal obstruction and diagnosing MMIHS. MRI can assess the normality of the intestinal tract not involved in the obstruction, but not multiple obstructions, necrosis and small urodigestive fistulas.

Intrauterine hemorrhage from an umbilical cord ulcer associated with fetal duodenal atresia: a case report

In the recent years, the association between congenital intestinal atresia and umbilical cord ulceration has been demonstrated; however, this complication is rarely encountered. To the best of our knowledge, only 14 cases on this association have been published previously. We encountered a case of acute intrauterine hemorrhage from an umbilical cord ulcer in a fetus with duodenal atresia that resulted in early neonatal death. There is little information available on the association between congenital intestinal atresia and umbilical cord ulceration. Greater understanding may alter the obstetric management. Although the prevention of sudden perinatal death is considered to be difficult, frequent fetal monitoring and detailed ultrasonographic examinations may facilitate the early detection of this condition, thereby enabling the rescue of the affected fetuses. Further investigation is required to establish the management protocol.