Prenatal diagnosis and management of congenital volvulus

Intrauterine volvulus: systemic review of the literature with pooled analysis

Our objective is to analyse the observations related to intrauterine volvulus and assess how clinical manifestations and treatment strategies impact prognosis. We conducted a comprehensive search on Pubmed and ClinicalTrials.gov from inception to July 2022, using search terms like "intrauterine volvulus" or "foetal volvulus," supplemented by manual scrutiny of reference lists in relevant texts and articles. Our review encompassed 57 case reports/case series, involving 88 cases. The presence of foetal bradycardia during prenatal visits (p = 0.002) and the existence of meconium cyst or pseudocyst (p = 0.038) significantly influence survival rates. Preterm labour occurred more frequently among cases resulting in mortality (54% vs 21%; p = 0.055). Our study's limitations include the inability to access all reported cases and reliance solely on available data. We advocate for vigilant monitoring of foetuses exhibiting signs of intestinal obstruction, and consideration of an emergent caesarean section as a pre-emptive measure before foetal biophysical profile deterioration worsens.

Prenatal imaging features and perinatal outcomes of foetal volvulus-A literature review

OBJECTIVE

To conduct a review of the literature on foetal volvulus with emphasis on prenatal imaging, pregnancy characteristics and clinical outcomes.

METHODS

A review of all published cases of foetal volvulus diagnosed prenatally and indexed in Medline, EBSCOhost, CINAHL, SOCIndex and Healthy Policy Reference Centre. Studies without antenatal sonographic signs of foetal volvulus and without a postpartum surgical diagnosis were excluded. Data were analysed for frequencies and distributions and tested for statistical significance.

RESULTS

Eighty-eight cases of foetal volvulus were identified from 58 published case reports/series. The most common ultrasound findings were dilated bowel/stomach (77.3%), polyhydramnios (30.7%) and whirlpool/snail sign (28.4%). Median gestation at diagnosis was 31.9 weeks (IQR 27-34) and mean gestation at delivery was 34.5 weeks (SD 2.8). Underlying aetiology included intestinal malrotation (15.9%), cystic fibrosis (14.8% of all cases, 32.5% of tested cases) and abnormal mesenteric fixation (12.5%). Complications included intestinal atresia (36.4%) and foetal anaemia (9.1%). The overall perinatal mortality rate was 14.5%.

CONCLUSION

Foetal volvulus is a rare condition with high rates of preterm birth and perinatal mortality. Intestinal malrotation and cystic fibrosis are common predisposing causes, although the majority are idiopathic. Bowel and/or gastric dilatation is by far the most common sonographic finding.

Omphalomesenteric Duct Remnant: A Rare and Unusual Cause of Intestinal Atresia

Intestinal atresia is generally considered to result from mesenteric vascular disruptions during fetal life. This report describes an unusual case of ileal atresia, resulting from an omphalic ring closure anomaly and an omphalomesenteric duct (OMD) remnant. A 2-day-old male neonate presented with bilious vomiting and abdominal distension. At laparotomy, the distal portion of the atretic ileum was entrapped within the umbilical ring, causing volvulus of the proximal dilated atretic bowel around the fixed distal bowel at the omphalic ring. This case report supports OMD remnants as a rare, potential cause of jejunoileal atresia.

Prenatal diagnosis of antenatal midgut volvulus: Specific ultrasound features

OBJECTIVE

To assess specific, direct, and indirect prenatal ultrasound features in cases of fetal midgut volvulus.

METHODS

Retrospective case series of neonatal volvulus, based on postnatal and prenatal imaging findings that occurred from 2006-2017. Prenatal and postnatal signs including the specific "whirlpool sign" were computed. Postnatal volvulus was confirmed by pathology examination after surgery or neonatal autopsy.

RESULTS

Thirteen cases of midgut volvulus were identified. Though not a specific sign, a decrease in active fetal movements was reported in eight patients (61.5%). The prenatal whirlpool sign was directly seen in 10 cases, while an indirect but suggestive sign, a fluid-filled level within the dilated loops, was present in five cases. No intestinal malrotation was observed. Pregnancy outcomes were two terminations of pregnancy, both associated with cystic fibrosis, one early neonatal death, three prenatal spontaneous regressions, and seven favorable outcomes after neonatal surgery with resection of midgut atresia.

CONCLUSIONS

Identification of the whirlpool sign or of a fluid-filled level within the dilated loops improves the accuracy of ultrasound findings for suspected volvulus. In the absence of total volvulus (in cases of intestinal malrotation) or association with cystic fibrosis, the prognosis appears good.

Prenatal Diagnosis of a Segmental Small Bowel Volvulus with Threatened Premature Labor

Fetal primary small bowel volvulus is extremely rare but represents a serious life-threatening condition needing emergency neonatal surgical management to avoid severe digestive consequences. We report a case of primary small bowel volvulus with meconium peritonitis prenatally diagnosed at 27 weeks and 4 days of gestation during threatened premature labor with reduced fetal movements. Ultrasound showed a small bowel mildly dilated with thickened and hyperechogenic intestinal wall, with a typical whirlpool configuration. Normal fetal development allowed continuation of pregnancy with ultrasound follow-up. Induction of labor was decided at 37 weeks and 2 days of gestation because of a significant aggravation of intestinal dilatation appearing more extensive with peritoneal calcifications leading to the suspicion of meconium peritonitis, associated with reduced fetal movements and reduced fetal heart rate variability, for neonatal surgical management with a good outcome.

Congenital duodenal obstruction: causes and imaging approach

Bilious emesis is a common cause for evaluation in pediatric radiology departments. There are several causes of congenital duodenal obstruction, most of which require elective surgical correction, but the potential of malrotation with midgut volvulus demands prompt imaging evaluation. We review the various causes of congenital duodenal obstruction with an emphasis on the approach to imaging evaluation and diagnosis.

Intrauterine midgut volvulus without malrotation: Diagnosis from the ‘coffee bean sign’

Fetal midgut volvulus is quite rare, and most cases are associated with abnormalities of intestinal rotation or fixation. We report a case of midgut volvulus without malrotation, associated with a meconium pellet, during the gestation period. This 2.79 kg, 33-wk infant was born via a spontaneous vaginal delivery caused by preterm labor. Prenatal ultrasound showed dilated bowel loops with the appearance of a ‘coffee bean sign’. This patient had an unusual presentation with a distended abdomen showing skin discoloration. An emergency laparotomy revealed a midgut volvulus and a twisted small bowel, caused by complicated meconium ileus. Such nonspecific prenatal radiological signs and a low index of suspicion of a volvulus during gestation might delay appropriate surgical management and result in ischemic necrosis of the bowel. Preterm labor, specific prenatal sonographic findings (for example, the coffee bean sign) and bluish discoloration of the abdominal wall could suggest intrauterine midgut volvulus requiring prompt surgical intervention.

Midgut volvulus with hemorrhagic ascites: a rare cause of fetal anemia

Fetal intestinal volvulus is a rare life-threatening condition usually manifesting after birth. It appears on prenatal ultrasound imaging as a twisting of the bowel loops around the mesenteric artery, leading to mechanical obstruction and ischemic necrosis of the bowel. Vascular compromise can result in bowel infarction and eventual perforation of the necrotic bowel, with the development of hemorrhagic fetal ascites and fetal anemia. We report a case of intrauterine midgut volvulus, suspected when ultrasound imaging revealed dilated bowel loops at 31 weeks' gestation, with fetal anemia also suspected on measurement of increased middle cerebral artery peak systolic velocity by Doppler ultrasound examination. Volvulus should be considered in the differential diagnosis when ultrasound imaging demonstrates dilated loops of bowel, especially in association with fetal ascites.

Midgut volvulus causing fetal demise in utero

Intestinal malrotation has an incidence of 1 per 6000 live births. The most serious consequence of malrotation is volvulus. Midgut volvulus is a rare condition in which the small bowel and proximal colon twist around the superior mesenteric artery, leading to a high-grade proximal bowel obstruction and vascular compromise of the intestine, thereby leading to infarction of the involved intestine. Midgut volvulus rarely occurs antenatally and is usually not lethal in utero. There are only 7 cases of intrauterine fetal demise caused by midgut volvulus reported in the literature. We report a case of intrauterine fetal demise at 38 weeks of gestation, due to cardiovascular failure and shock from midgut volvulus. Non-specific abnormalities, including ascites and dilated bowel, had been seen on the antenatal ultrasound from the 15th week of gestation. In addition to the volvulus, the fetus had intestinal atresia and arthrogryposis.

The etiologic role of intrauterine volvulus and intussusception in jejunoileal atresia

PURPOSE

Although intussusception has been reported as quite a rare cause of jejunoileal atresia (JIA), pediatric surgeons have noted the frequent presence of intussusception as well as volvulus at surgery. The aim of this study was to investigate the contribution of intrauterine intussusception and volvulus to the development of JIA.

METHODS

In 48 newborns (24 boys and 24 girls) treated for JIA at our hospital between 1978 and 2004, the operative and pathologic findings were reviewed.

RESULTS

Intussusception was responsible for gap and cord type atresia in 12 cases (25%). The cord showed an atrophic intestinal lumen in 2 cases. Volvulus was observed in 13 cases. Volvulus and intussusception were simultaneously noted in 1 case. This suggested that intussusception was the cause of the atresia, whereas volvulus was a secondary event. Neither intussusception nor volvulus was observed in high jejunal, apple peel, or multiple atresia.

CONCLUSIONS

Intrauterine volvulus and intussusception were commonly observed in single mid- and low JIA. Thus, intrauterine intussusception may be a common cause of gap and cord type JIA. Volvulus may not only cause JIA but also result from anatomic changes after the development of JIA in some cases.

Antenatal small-bowel volvulus without malrotation: ultrasound demonstration and discussion of pathogenesis

We present a case of volvulus without malrotation in a twin fetus where serial antenatal US assisted in the diagnosis and ensured prompt postnatal surgical treatment. When a fetal subumbilical intestinal mass is seen, changing its echogenicity from complex to cystic, and associated with progressive proximal small-bowel obstruction and/or bowel perforation, small-bowel volvulus should be included in the differential diagnosis.