Meconium peritonitis: A rare neonatal surgical emergency.

Abstract

Sir, We present two cases of meconium peritonitis, a rare neonatal surgical emergency. The first baby, 1.8 Kg in weight, born at 32 weeks gestation had Apgar score of 8/10 at 1 min, heart rate (HR) was 164/min, respiratory rate (RR) 54/min and capillary refill time (CRT) 3 s. Abdomen was distended with a hard palpable lump in the supra-umbilical region. There was respiratory distress with intermittent apnoeic episodes for which the baby was intubated. Ultrasonography at 29 weeks showed ascites, bilateral pleural effusion, calcification along the liver surface and an abdominal lump. Abdominal radiograph revealed a centrally located large calcific lesion [Figure 1]. Haemoglobin was 19.2 g %, leucocyte count 17,700/mm3, C-reactive protein (CRP) 192 mg/L (normal <10 mg/L), creatinine 1.3 mg% and electrolytes and blood gases were normal. Diagnosis of meconium peritonitis was made and baby was posted for emergency laparotomy on day 1 of life. Anaesthesia was induced with sevoflurane in oxygen (O2) and maintained on sevoflurane, O2, air (50:50) with fentanyl 2 μg/kg for analgesia. Peripherally inserted central catheter (PICC) (1 Fr G) was inserted through the right cephalic vein. There was an episode of hypotension where blood pressure fell to 42/20 mm Hg for which fluid bolus was given and dopamine infusion started at 10 μg/kg/min. The large calcific deposit was removed, meconium was aspirated and suture of ileal perforation was done. Baby was electively ventilated and extubated on the 4th post-operative day. Figure 1 Chest and abdominal radiograph showing intra-abdominal calcification in the central location The second baby weighing 2 kg was delivered at term by caesarean section. Apgar score was 9/10 at 1 min, HR: 142/min, RR: 48/min and CRT < 3 s. Abdomen was distended. Ultrasound revealed dilated bowel loops with echogenic contents and free fluid suggestive of meconium peritonitis. Haematological investigations were normal. Baby was posted for emergency laparotomy on day 1 of life. Anaesthesia was induced with sevoflurane in O2. Rocuronium 1.2 mg/kg was administered and modified rapid sequence induction was performed with cricoid pressure and gentle ventilation. Exactly 45 s later airway was secured with 3.5 mm ID endotracheal tube. Anaesthesia was maintained on sevoflurane at 1.2 MAC, air, O2 mixture (50:50) and fentanyl 2 μg/kg. Adhesiolysis with excision of meconium pseudocyst in jejunum was performed. PICC (1 Fr G) was inserted through left great saphenous vein. Trachea was extubated on table. Meconium peritonitis is an aseptic chemical peritonitis which results from perforation of the gut in utero.[1] Incidence is 1 in 35,000 live births.[2] Possible causes include mesenteric ischaemia, volvulus, intestinal atresia, meconium plugs, internal hernia and Hirschsprung's disease.[3] Other associations include chromosomal aberrations and cystic fibrosis. Perforation of the intestines in utero results in leakage of meconium into the peritoneal cavity. Inflammatory reaction and chemical peritonitis occurs, which subsequently seals forming intra-abdominal calcifications. Huge abdominal cyst formation and ascites may develop which can cause foetal cardiac insufficiency and cardiorespiratory compromise after birth.[3] Prenatal ultrasound is diagnostic.[4] Management begins at delivery. Fluid resuscitation may be needed if the baby is in shock. Bag-mask ventilation may further aggravate bowel distension. Endotracheal intubation with controlled ventilation is preferable. Initial stabilisation of cardiopulmonary parameters and blood gas analysis, CRP, lactates, haematocrit, blood count, platelets, electrolytes, culture and cross match are done. Inotropes are started early if haemodynamic instability does not respond to fluid boluses. Chest and abdominal radiographs, ultrasound of abdomen and echocardiography are preferable as persistent pulmonary hypertension may complicate the management. These babies are then managed in a staged approach. An abdominal drainage with ultrasound guidance under local anaesthesia is preferred in critical neonates. Exploratory laparotomy with adhesiolysis and enterostomy is done in haemodynamically stable babies. Finally, stoma closure is performed. Prolonged antibiotic administration postoperatively and enteral nutrition may warrant PICC insertion. Complications such as wound infection, intestinal fistula, abdominal abscess, cerebral haemorrhage due to disseminated intra-vascular coagulation, sepsis and multi-organ failure may occur.[3] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.