CAROLINE BUCKLEY

CASE OF THE YEAR

MATERNAL DETAILS

• 21 years old, primigravida

• O Rhesus Positive, antibody negative

• Rubella Immune, Hep B, HIV negative

• Non-smoker, no alcohol

• No significant past medical history, scans normal

LABOUR & DELIVERY

• Spontaneous onset of labour at 41+3 weeks

• Rupture of membranes 3 hours prior to delivery

• No pyrexia in labour, no offensive liquor

• Cephalic presentation, SVD

• Apgar scores 9 & 10

• Birth weight 3.995kg

NEWBORN EXAMINATION

Performed at nine hours of age

•No concerns

•Abdomen soft, not distended. Small soft ‘lump’, near umbilicus Not tender

•Well baby, normal movements and tone

‘….can you come and have a look at this baby. I’m sure it’s nothing, it’s not urgent. She’s well, she’s feeding, but there’s just something that doesn’t feel right when I felt her abdomen…’

midwife, low dependency delivery unit

WHAT DO YOU THINK ?IS THERE ANYTHING YOU WOULD LIKE TO KNOW ?

WHAT DO WE WANT TO KNOW..?

•Pink, alert and active

•Feeding - formula via bottle, some mucousy vomits

•Bowels not opened yet (but nine hours old)

WHAT DO YOU THINK ?WHAT WOULD YOU LIKE TO DO ?

THINGS TO THINK ABOUT

•Review full history – ensure that no meconium was passed prior to delivery

•Examine notes for any evidence of polyhydramnios or other abnormalities on antenatal scans, e.g. dilated loops of bowel

•Anus appeared to be patent on examination

OUR PLAN…

• Continue to demand feed

• Observe closely, await passage of meconium

• Review in the morning – if passed meconium by then and remains well, can go home.

• Contact the neonatal team if any concerns…

…IN THE MORNING

Overnight, baby had fed …. but bowels not opened !

Baby is now 18 hours of age

WHAT DO YOU THINK ?WHEN SHOULD YOU START TO BE CONCERNED ?

ON EXAMINATION…

• Baby awake, alert, rooting

• Abdomen now distended and tense

• Green bilious vomit as soon as baby handled

ABDOMINAL DISTENSION

•Can be moderate or extreme

•Suggests an intestinal obstruction or intra-abdominal mass

BILIOUS VOMITING IS ALWAYS PATHOLOGICAL

NEVER IGNORE IT

INTESTINAL OBSTRUCTION

Infant presents with some or all of the following features:

•Bile stained vomiting•Abdominal distension•Visible peristalsis•Delayed passage of meconium•Dehydration

CLASSIFICATION OF INTESTINAL OBSTRUCTION

Classified depending on the site of the blockage (large or small bowel), or whether this is anatomical or functional

•Pyloric stenosis•Duodenal obstruction•Anorectal malformations•Hirchsprungs disease•Meconium ileus

OUR PLAN…

• Admit to the NNU immediately

• Nil by Mouth

• Nasogastric tube

• Abdominal x-ray

• IV fluids

ABDOMINAL X-RAY

meconium ileus

MECONIUM ILEUS

• Bowel obstruction caused by highly viscid meconium within the lumen

• Cystic Fibrosis (CF) is almost always the cause

• Around 15% of infants with CF will present in this way

MECONIUM ILEUS

Clinical features:•Antenatal history of echogenic bowel on USS•Family history of CF or parental CF carrier status•Most common site of obstruction is in the distal ileum•Progressively worsening bilious vomiting•Abdominal distension•Palpable and sometimes visible bowel loops•Palpable abdominal mass•Failure to pass meconium

THEN WHAT HAPPENED…

• Baby transferred to the RVI urgently

• Bowel surgery performed that day – formation of a stoma

• Sweat test and genetic testing for Cystic Fibrosis

…positive

INHERITANCE OF CYSTIC FIBROSIS

REMEMBER...!

• You would expect all babies to pass meconium within 24 hours of birth

• Bile stained vomiting is always pathological

• Abdominal distension might suggest an intestinal obstruction or intra-abdominal mass

THANK YOU FOR LISTENING !