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

Abstract

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 CASE REPORTA 26-year-old woman, gravida 3, para 1, with a history of one termination of pregnancy and one normal delivery underwent a fetal anatomy scan at 20 weeks' gestation, which was normal. At 31 weeks' gestation, the woman presented with reduced fetal movements and abdominal pain, which had been present for the preceding 48 h. Cardiotocography (CTG) showed no episodes of high variation, a short-term variation of 3.2 and reduced baseline variability of < 5 beats per min without accelerations. Fetal head circumference and femur length were on the 50 th percentile, but abdominal circumference was > 95 th percentile for gestational age and polyhydramnios was noted. Fetal ascites and dilated bowel loops were observed (Figures 1 and 2), but there was no evidence of pleural or pericardial effusion. No other fetal abnormalities were noted. Umbilical artery Doppler imaging showed positive end-diastolic flow. However, fetal movements were absent and the peak systolic velocity in the middle cerebral artery was increased, suggesting fetal anemia as a possible cause of the abnormal fetal heart rate patterns. A live 1860-g male was delivered by emergency Cesarean section, with Apgar scores of 3 and 6 at 1 min and 5 min, respectively. Umbilical artery pH was 6.9 and the base excess was −12.0. The neonate was anemic (hemoglobin 10.8 g/dL), and was resuscitated with endotracheal intubation and blood transfusion. The abdomen was distended and tense with dark discoloration of the skin (Figure 3).Ultrasound examination at 2 h after birth showed a large amount of free fluid mixed with echogenic particles

Congenital Midgut Volvulus Associated with Fetal Anemia

“…Both our and the 2 previously described cases [10,11] indicate an association of fetal anemia with congenital volvulus. It is believed that coexisting fetal anemia is a consequence of impaired venous return from the dilated bowel loop which leads to passive congestion [12] .…”

“…So far, only one analogous case has been described in the literature [10] . It concerned a fetus in whom bowel dilatation, ascites and an increased value of PSV in MCA were found at 31 weeks' gestation.…”

Ascites, anemia and (intestinal) atresia

“…Noreldeen described a preterm neonate with midgut volvulus associated with hemorrhagic ascites. 4 This presented at 31 weeks of gestation with ultrasound findings of polyhydramnios, fetal ascites, dilated bowel loops and increased MCA PSV suggestive of fetal anemia. Upon emergency Cesarean delivery, the neonate had abdominal distension with bluish discoloration of the skin (Cullen's sign).…”

What is your diagnosis?

“…However, there will always be cases where we cannot reach a definitive diagnosis, and close follow-up of these cases with serial ultrasound scans and fetal well-being evaluation are clearly required. Fetal demise in case of volvulus occurs secondary to bowel infarction, hemorrhagic ascites, and fetal anemia (14,15). Accordingly, to predict fetal demise secondary to hemorrhagic ascites, middle cerebral artery Doppler and non-stress testing becomes critical (14,15).…”

“…Fetal demise in case of volvulus occurs secondary to bowel infarction, hemorrhagic ascites, and fetal anemia (14,15). Accordingly, to predict fetal demise secondary to hemorrhagic ascites, middle cerebral artery Doppler and non-stress testing becomes critical (14,15). Increased peak systolic velocity in middle cerebral artery Doppler examination shows anemic condition of the fetus secondary to bowel infarction and hemorrhage.…”