Midgut Herniation Research Articles

Color Doppler, HDlive, and HDlive Silhouette features of an umbilical cord cyst before 11 weeks of gestation: Diagnostic value.

We describe transvaginal color Doppler, HDlive, and HDlive Silhouette features of an umbilical cord cyst (UCC) before 11 weeks of gestation. In this cohort study, 135 transvaginal dating scans were performed at 7 to 10 + 6 weeks of gestation, and 17 UCCs were identified (12.6%). UCC was evaluated using color Doppler, HDlive, and HDlive Silhouette. The clinical characteristics, pregnancy courses, and outcomes were also investigated. UCC location was on the fetal side in six cases, at the free loop in 10 cases, and on the placental side in one case. There were seven single and 10 multiple cysts. Cyst diameters ranged from 3.3 to 11.3 mm (mean, 5.6; standard deviation, ±2.1). Blood flow inside the cyst was noted in three cases (17.6%). HDlive clearly showed the spatial relationships among UCC, the umbilical cord, midgut herniation, yolk sac, and embryo. Location of UCC could be clearly identified with HDlive. HDlive Silhouette showed central cysts inside UCCs in seven cases (41.2%). HDlive Silhouette also clearly demonstrated the sac of midgut herniation in the umbilical cord in 12 cases (70.6%). All UCCs resolved before 15 weeks (mean, 11.1 weeks; standard deviation, ±1.5). All fetuses with UCCs showed good neonatal outcomes. The incidence of UCC was high compared with that in previous reports. Color Doppler, HDlive, and HDlive Silhouette may provide information on the nature and origin of UCCs before 11 weeks of gestation. UCC before 11 weeks of gestation may be a common, transient, and benign finding.

Neonatal presentation of transected sigmoid colon following umbilical cord clamping: Hernia of umbilical cord

The umbilicus is a site of numerous embryopathies involving vessels, urachus, mid gut herniation, anterior abdominal wall defects and congenital cysts. Owing to lack of awareness, umbilical cord hernia (HUC) is often misdiagnosed and underreported, with limited data in the literature. We report an isolated case of congenital HUC and perinatal transection of the sigmoid colon during cord ligature by a midwife in a local health center. A six-day old female neonate presented with discharge of fecal matter through the umbilicus. The clamped cord, became swollen and auto-amputated on day of life three, after which fecal discharge was from the stump was noted. On examination a visible bowel loop containing stool was seen in the umbilical cord. We proceeded with surgical intervention via a small umbilical incision, with findings of transection of the sigmoid colon, no peritoneal contamination, and primary anastomosis was performed. There was event free recovery postoperatively. HUC is poorly understood and often misdiagnosed as omphalocele minor. One should be cognizant of HUC when noting swelling at the base of the cord so as to avoid any inadvertent iatrogenic enterotomy by close umbilical clamping.

Sonographic detection of fetal abnormalities before 11 weeks of gestation.

Sonographic detection of fetal abnormalities before 11 weeks of gestation.

Evaluation of First-Trimester Physiological Midgut Herniation Using Three-Dimensional Ultrasound

Introduction: The aim of this study was to investigate the development of midgut herniation in vivo using three-dimensional (3D) ultrasonographic volume and distance measurements and to create reference data for physiological midgut herniation in ongoing pregnancies in a tertiary hospital population. Materials and Methods: The transvaginal 3D ultrasound volumes of 112 women, seen weekly during the first trimester of pregnancy, were obtained and subsequently analysed in a virtual reality environment. The width of the umbilical cord insertion, the maximum diameter of the umbilical cord, and the volume of midgut herniation were measured from 6 until 13 weeks gestational age (GA). Results: All parameters had a positive relation with GA, crown-rump length, and abdominal circumference. In approximately 1 of 10 volumes no midgut herniation could be observed at 9 and 10 weeks GA. In 5.0% of the fetuses the presence of midgut herniation could still be visualised at 12 weeks GA. Conclusion: Reference charts for several dimensions of physiological midgut herniation were created. In the future, our data might be used as a reference in the first trimester for comparison in case of a suspected pathological omphalocele.

Midgut malrotation with chronic abdominal pain

Abnormalities in midgut rotation occur during the physiological herniation of midgut between the 5th and 10th week of gestation. The most significant abnormality is narrow small bowel mesentery which is prone to volvulus. This occurs most frequently in the neonatal period, less commonly midgut malrotation presents in adulthood with either acute volvulus or chronic abdominal symptoms. It is the latter group that represents a diagnostic challenge. We report a case of a 17-year-old male patient who presented with 10-year history of nonspecific gastro-intestinal symptoms. After extensive investigation the patient was diagnosed with midgut malrotation following computed tomography of abdomen. The patient was treated with a laparoscopic Ladd's procedure and at 3 months he was gaining weight and had stopped vomiting. A laparoscopic Ladd's procedure is an acceptable alternative to the open technique in treating symptomatic malrotation in adults. Midgut malrotation is a rare congenital anomaly which may present as chronic abdominal pain. Abdominal CT is helpful for diagnosis.

Congenital hernia of the cord

Several embryopathies involve umbilicus including midgut herniation, omphaloceles, urachal and vascular anomalies. Although described earlier, hernia into umbilical cord has not found enough mention in the literature. Poor understanding of its clinical characteristics has made to miscategorization of this entity as "omphalocele minor" by many. Some of these undergo spontaneous reduction or epithelialisation if left alone. The present study describes a series of four consecutive cases of this entity and describe their clinical characteristics, associated GI anomalies and possible embryogenesis.

Early embryo development in the elephant assessed by serial ultrasound examinations

The elephant has an extraordinary long pregnancy, lasting 21 months. However, knowledge on embryo development is limited. To date, only single morphological observations of elephant embryo development associated with placentation are available, all lacking correlation to gestational age. The present study describes morphological characteristics of early embryo development in the elephant with exact biometric staging. Six pregnancies in five Asian and one African elephants with known conception dates were followed by 2D and 3D ultrasound, covering the embryonic period from ovulation to day 116 post-ovulation. The embryonic vesicle was earliest observed was on day 50 p.o. The proper embryo was not detected until day 62 p.o. Embryonic heartbeat was first observed on day 71 p.o. The allantois, which became visible as a single sacculation on day 71 p.o. was subdivided in four compartments on day 76 p.o. By day 95 p.o., head, rump, front and hind legs were clearly distinguished. Between days 95 and 103 p.o. the choriovitelline placenta was replaced by the chorioallantoic placenta. A physiological midgut herniation was transiently present between days 95 and 116 p.o. On the basis of the late appearance of the embryonic vesicle, delayed implantation in the elephant is discussed. The study provides a coherent description of elephant embryonic development, formation of the extraembryonic organs and their role in placenta formation, all of which are of interest for both comparative evolutionary studies and the improvement of assisted reproduction techniques.

Three-Dimensional First-Trimester Transvaginal Diagnosis of Alobar Holoprosencephaly Associated with Omphalocele in a 46,XX Fetus

A three-dimensional (3D) transvaginal diagnosis of alobar holoprosencephaly (HPE) with associated omphalocele is reported at 12 weeks, 3 days gestation. Diagnosis of HPE was based on visualization of a single holoprosencephalic cavity with absent falx and basal ganglia and omphalocele by the presence of abdominal wall defect with mid-gut herniation. Chorionic villus sampling showed a normal 46,XX karyotype. 3D volumetric reconstruction allowed a more detailed definition of the anatomic landmarks of the lesion, including visualization of a thin rim of cortical mantel within the prosencephalic cavity, the dysmorphic face with flattened nose, and the abdominal eventration that looked like an abdominal air bag on 3D volumetric reconstruction.

Herniation through the foramen of Winslow presenting as obstructive jaundice

Herniation through the foramen of Winslow is a rare variety of paraduodenal hernia. We report a 19-month-old child with obstructive jaundice due to midgut herniation through the foramen of Winslow with associated volvulus. The herniation and volvulus were precipitated by intestinal malrotation. The patient underwent extraamniotic silo repair of exomphalos major in the neonatal period. Investigation for malrotation is recommended after extraamniotic closure of exomphalos.

WS16‐02Sonoembryology using intrauterine sonography

Our first purpose was to describe embryonic anatomic structures by use of IUS with a 20‐MHz flexible catheter‐based, high resolutions, real‐time miniature transducer. The number and the clarity of structures increased from 7 to 8 weeks of gestation; however, the image quality was degenerated because of the increasing fetal size at 9 weeks. At 8 weeks secondary brain vesicles, spine, midgut herniation, liver, upper and lower limb buds, and sacral tail were visualized in all fetuses. The four‐chamber view was first identified at 8 weeks, as were fingers or toes. The stomach was first noted at 9 weeks.Second purpose was to compare the ultrasound visualization of the early first‐trimester embryo using TVS and IUS as 6–8 weeks of gestation. The ability to view most organs was better with IUS compared to TVS, and this was especially true for the brain, spine, heart, liver, midgut herniation, extremities, and sacral tail. Moreover, it was possible to obtain finer image quality of very small embryonic structures with IUS than with TVS.Third purpose was to evaluate embryonic organ growth (liver, heart, and brain vesicles) using IUS in the early first trimester of pregnancy. The significant good correlation between each parameter and gestational age was obtained.Fourth purpose was to visualize normal embryonal surface anatomic structures using 3D‐IUS at 7–9.9 weeks gestational age. At week 8, prominent forehead was evident, and upper and lower limbs and midgut herniation were clearly depicted. At week 9, fingers and toes were depicted as small digital rays, and the sacral tail protruded caudally. At week 10, embryonic face and fingers were clearly shown.

Three-dimensional intrauterine sonography in the early first-trimester of human pregnancy: preliminary study.

Our purpose was to visualize normal embryonal surface anatomic structures using three-dimensional (3D) intrauterine sonography with a 20 MHz flexible catheter-based high-resolution real-time miniature transducer in the early first trimester of pregnancy. A total of 15 women about to undergo therapeutic abortion at 7-9.9 weeks gestational age were studied by means of 3D intrauterine sonography with a specially developed catheter-based high-resolution real-time miniature (2.4 mm in outer diameter) ultrasound transducer (20 MHz). This imaging system can provide conventional 2D intrauterine sonographic images and can also generate within seconds high-quality 3D images in the surface and transparent mode. At week 8, prominent forehead was evident, and upper and lower limbs and midgut herniation were clearly depicted. At week 9, fingers and toes were depicted as small digital rays, and the sacral tail protruded caudally. The midline cranial ectodermal cleft was also identified. At week 10, embryonic face and fingers were clearly shown. 3D intrauterine sonography provides a novel means for visualizing of surface anatomic structures of the human embryo in utero. These results suggest that 3D intrauterine sonography can become an important modality in future embryological research and in detection of embryonic developmental disorders in the early first-trimester pregnancy.

FIRST-TRIMESTER SONOGRAPHY OF PHYSIOLOGICAL MIDGUT HERNIATION AND EARLY DIAGNOSIS OF OMPHALOCELE

Embryological development was investigated by ultrasonography in a longitudinal study of 18 normal pregnancies. The appearance of midgut herniation was studied and if present, its circumference was valued. In addition, patients with an elevated risk for anomalies were scanned between 10 and 16 weeks of gestation. In 17 fetuses, the diagnosis of omphalocele was made between 11 and 16 weeks. The ratio between the circumference of the omphalocele and abdomen was calculated and the contents of the omphalocele were evaluated. Eight of the fetuses had an abnormal karyotype and a mean omphalocele/abdomen ratio of 0.38 (SD 0.191), whereas the mean ratio of omphalocele and abdomen in the eight euploid fetuses was 0.88 (SD 0.291). Regarding the contents of the omphalocele, mainly bowel loops were eviscerated in all fetuses with an abnormal karyotype. The contents of the omphalocele sac in the euploid cases contained liver in all eight fetuses. In 16 out of 17 anomalous fetuses (91 per cent), associated findings were detected. Nuchal translucency was the most frequently visualized concurrent finding and its occurrence was associated with an abnormal chromosome pattern. A small sac size is a strong indication for aneuploidy, especially in combination with nuchal translucency. Prior to 12 weeks of gestation, the diagnosis of omphalocele can be made in cases of a large omphalocele.

Intrauterine ultrasonographic assessments of embryonic development

OBJECTIVE: Our purpose was to describe embryonal anatomic structures by use of intrauterine ultrasonography with a 20 MHz flexible catheter-based, high-resolution, real-time miniature transducer. STUDY DESIGN: Thirty-four women about to undergo therapeutic abortion from 7 to 9.9 weeks' gestation were studied with specially developed catheter-based, high-resolution, real-time miniature (2.4 mm outer diameter) ultrasonography transducer (20 MHz). A percentage of anatomic structures visualized at each gestational age is presented. RESULTS: The number and the clarity of structures increased from 7 to 8 weeks of gestation; however, the image quality was degraded because of the increasing fetal size at 9 weeks. At 8 weeks secondary brain vesicles, spine, midgut herniation, liver, upper and lower limb buds, and sacral tail were visualized in all fetuses. The four-chamber view was first identified at 8 weeks, as were fingers or toes. The stomach was first noted at 9 weeks. The umbilical cord cyst was visualized in 8% of embryos at 7 weeks' gestation and in 29% of embryos at 8 weeks. One cystic hygroma was diagnosed at 8 weeks 5 days. CONCLUSION: Intrauterine ultrasonography provides information on the visualization of anatomic structures of the embryo. In this limited series one embryonic malformation was demontrated, and thus there is a potential for its use in the detection of malformations. These results suggest that intrauterine ultrasonography has the potential to be a supplement to transvaginal ultrasonography during the first trimester in high-risk pregnancies.

Early development of the abdominal wall, stomach and heart from 7 to 12 weeks of gestation: a longitudinal ultrasound study

The purpose of this ultrasound study was to describe longitudinally the normal embryonic development in vivo. Twenty-nine healthy pregnant women were examined five times each with transvaginal ultrasound between 7 and 12 weeks of gestation measured from the last menstrual period. Structures such as the midgut herniation into the umbilical cord, the stomach and the heart were recognized and measured. It was possible to identify the physiological midgut herniation during weeks 7-8. It was always present from 8.5 to 10.5 weeks. At 12 completed weeks, the gut was retracted into the abdominal cavity for all the fetuses. We visualized the stomach in nine embryos (31%) during week 8, in 22 embryos (76%) before 10 weeks, and in all fetuses before 11 weeks. The heart rate increased rapidly to a mean of 175 beats per minute (bpm) at the beginning of week 9. Thereafter it decreased slowly to a mean of 166 bpm at 12 weeks. The mean heart diameter was 22% of the crown-rump length at 7 weeks, 17% at 9 weeks and only 13% at 12 weeks.

Fetal midgut herniation into the umbilical cord: improved definition of ventral abdominal anomaly with the use of transvaginal sonography.

The most common anomalies of the fetal ventral abdominal wall include omphalocele and gastroschisis. Umbilical cord hernia is another abdominal wall defect that is poorly defined and usually mistakenly considered as a small omphalocele. The present report describes the sonographic features and clinical significance of four cases of umbilical cord hernia identified transvaginally in the early second trimester of pregnancy. These cases seemed to present a different entity from that of simple omphalocele. The transvaginal sonographic approach provided a clear image of the midgut protruding into the umbilical cord, precise localization of cord insertion in the region of the umbilical ring. Doppler flow evaluation of the umbilical vessels and their relation to the protruding mass. Serial sonographic observations revealed a stable umbilical cord mass in three fetuses, and an enlarging mass in one. Normal karyotype was determined and no associated malformations were detected prenatally. However, in one case that underwent immediate correction of the hernia after delivery at term, the neonate was subsequently found to have pulmonic stenosis and severe neonatal seizures developed at 4 months of age. In two cases, pregnancy was terminated due to parental request. The fourth fetus was delivered vaginally at term and catastrophic division of the umbilical cord containing a loop of small intestine was avoided only by the diligent observation of the midwife. We suggest that umbilical cord hernia is a distinct anomaly originating at a different stage of embryogenesis, thereby having a unique clinical significance, unlike simple omphalocele. Umbilical cord hernia should therefore be defined and considered as a separate entity.

Sonography of Fetal Midgut Herniation: Normal Size Criteria and Correlation with Crown-Rump Length

Sonography of Fetal Midgut Herniation: Normal Size Criteria and Correlation with Crown-Rump Length

Sonography of fetal midgut herniation: normal size criteria and correlation with crown-rump length.

Forty-eight fetuses were prospectively evaluated to (1) determine the normal size range of herniated midgut and (2) correlate sonographically the timing of midgut herniation with CRL. All fetuses of CRL 38 mm or less, and two of six fetuses with a CRL of 40 to 42 mm, demonstrated midgut herniation. No fetuses with a CRL greater than 44 mm had this finding. The cord containing midgut increased roughly from 4 to 7 mm, in maximum dimensions, for CRL of 19 to 41 mm. An anterior abdominal wall mass greater than 7 mm at any CRL, or of any size in a fetus of CRL greater than 44 mm, is suggestive of a fetal anomaly. Alternatively, a cord base "mass" within the 4 to 7 mm range for a CRL of 19 to 44 mm can be considered normal and not to require any follow-up.

Transvaginal sonography at 5 to 14 weeks' gestation: fetal stomach, abnormal cord insertion, and yolk sac.

Transvaginal ultrasound evaluation of the fetal digestive system was performed on 1000 fetuses at 5 to 14 weeks' gestation. The normal physiologic process of the midgut herniation into the cord as well as the embryonal connection between the yolk sac and fetus were detected. Peristalsis of the stomach was noted as early as 14 weeks' gestation. Because gastric emptying is probably improper at this age, gastric pseudomasses were visualized in some cases.

First-trimester midgut herniation: A high-frequency transvaginal sonographic study

The application of high-frequency transvaginal sonography offers new opportunities in scanning for malformations during the first trimester of pregnancy. Scanning of the anterior abdominal wall and the umbilical cord insertion at this gestational age is feasible. A cross-sectional study of 61 embryos-fetuses from 7 to 12 weeks of gestation was performed to observe the physiologic midgut hernia. This herniation was detected in 64% of the cases at 8 weeks, in 100% during weeks 9 and 10, and in 25% at 11 weeks' gestation. None of the fetuses studied at 12 weeks had a midgut herniation. Vaginal sonography of the well-dated fetus at 12 weeks can confirm the final development of the anterior abdominal wall.

Dating the early pregnancy by sequential appearance of embryonic structures

A total of 97 transvaginal scans were performed from 4 to 12 weeks' gestation in normal and accurately dated gestations. The sequential appearance of six structures were examined: (1) the gestational sac only was present during week 4; (2) the yolk sac appeared in week 5; (3) the fetal pole with detectable heart motion was first seen in week 6; (4) the single unpartitioned ventricle in the brain marked week 7; (5) the falx cerebri appeared during week 9; and (6) the appearance and the disappearance of the physiologic midgut herniation were seen in week 8 and week 11, respectively. Inasmuch as the time in gestation at which these structures appear characterizes the gestational age more than any measurement at this age, we propose a practical method to determine the correct gestational age in early first-trimester pregnancy.