Meconeum Peritonitis : A Case Report

Meconeum Peritonitis ( MP ) maybe diagnosed if there is an area of

hyperechogenic density within the infants bowel on the second and third trimesters.
Studies involving neonates revealed a prevalence of MP to be 1: 35.000 live births.
MP results from a sterile chemical reaction from intra uterine ileum perforation
Secondary inflamatory response are production af liquids which forms ascites,fibrosis,
calcification and sometimes a cyst formation. Results of these process varies therefore
resulting in four different types of MP ; Fibroadhessive, cystic, diffuse and one which
resolves. We report one case of MP as follows :
Case Report
A woman of 35 YO, gravida 2, 24-25 wks was reffered by an Ob/Gyn with
hydrops fetalis for further investigation and treatment. She had a history of cesarean
section due to APB caused by placenta previa. LMP 09-09-2006. When reffered, the
patient had complaints of a larger abdomen compared to her gestational age and was a
little distended. No medical abnormalities were found. Blood type is B, Rh (+). On
sonographic examination, revealed a singleton live , male fetus , breech presentation.
Fetometry revealed : BPD 6,62cm (25W 3D), AC 25.93cm (30W 1D), FL 3.74cm (21W
6D) with an avarage of 26W+3D, EFW 1224 gr.
It revealed an ascites of the fetus with echogenic bowel and polyhydramnion. There were
no other anatomical disorders detected. There were no accumulation of fluids within
other body cavities. Placenta was on the posterior with a width of 3,99 cm within the
central area.
Doppler examination of the umbillical artery : S/D ratio 3.24 with pulsatile index of
1,16. Peak systolic velocity on middle cerebral artery 27,9 cm/second.( <1,5MoM) which
means normal value. ( there were no anemia of the fetus )
Serological examination TORCH ; toxoplasmosis IgG +, IgM -, Rubella IgG +, IgM-,
Cytomegalovirus IgG+ , IgM -, Herpes virus IgG-, IgMIn this case, amniocentesis was performed to examine caryotyping with a result of 46XY
chromosome.
A serial amnioreduction was performed because of polyhydramnion an paracenthesis
was also done because of massive ascites of the fetus which may cause excessive
pressure on the diaphragm. A culture was performed on the paracenthesis fluid and was
revealed sterile.
When GA was above 34 weeks, there were a reduction of ascites fluid and amniotic
volume became normal.
Then a weekly serial sonography was performed. Upon 40-41 weeks GA, spontaneous
labour was performed by means of vacuum extraction because of an ineffectiveness to
bear down.
A male fetus ,3300gr,52 cm long,Head circumference 35cm,chest circumferrence 34cm,
Abdominal circumfference 33cm AS:8-10, Hb 16,9g%, Alb 4 gr%, mixturition :N,
defecation : N ,breastfeeding :N

Abdominal X-ray was performed and revealed gas filling the upper up to the lower
portion of the bowels.
CT scan was pserformed to reveal signs of calcification of the cerebrum which is related
to cytomegalovirus infection. There were no intracranial calcification, a hypodense mass
was found in the occipital,sulcus and gyrus seems normal.
Evaluation by neurosurgeon colleagues found intracranial haemorrhage of the occipital
and was treated conservatively. The latest condition of the fetus as per this report was in
good condition.
Disccussion
Experimental researches on animals points that calcification can be detected after
8 days after meconial leackage into the peritoneal cavity. The most frequent etiological
causes of MP include : ischaemical lession of the ileum which is related to mechanical
obstruction.( atresia, volvulus,inttusuception,congenital bands,diverticulum of Meckel
and internal hernia)
Those above affects up to 50% of MP cases.
MP can also be caused by viral infection (cytomegalovirus,parvovirus B19). Meconeal
ileus is also a known causative factor affecting less than 25% of MP cases.
Prenatal sonography to support the diagnosis of MP must reveal : intaabdominal
calcification, ascites, polyhydramnion and bowel dilatation.
Foster et al reported the incidence of sonographical findings of 7 cases of MP :
intraabdominal calcification 86%,ascites 64%,polyhydramnions 71%,signs of bowel
obstruction 46%.
There are three main types of MP which can be identified by prenatal ultrasound :
cystic ( pseudocyst meconeum), diffiuse and fibroadhessive.
Pseudocyst meconeum is the most frequent finding of MP cases which has an image of
hyperechoic mass. Ascites is also frequently found. Diffuse MP is usually associated with
polyhydramnion, fetal ascites and intraabdominal calcification. The fetal abdominal wall
seems thick because of edema. Fibroadhessive MP is due to calcium deposits within the
peritoneum which may close the lession of the bowel.