Obstetrical and neonatological aspects of a child with atresia of the small bowel

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Abstract
A patient was admitted to the hospital in the 31st wk of gestation because of reduced sensation of fetal movements and a pathologic fetal heartrate tracing. At first no underlying pathology could be found. After a week she developed a polyhydraminos. After repeated ultrasonographic examinations an atresia of the fetal small bowel was suspected. The diagnosis could be confirmed after birth and on the same day the child was operated on. At atresia of the ileum was found. After liberal resection of the atretic part, recovery was complete. The malformation has an incidence of 1:12,500-20,000. The etiology is thought to be a temporary or definite obstruction of a mesenterial artery branch, supplying the small bowel of the fetus. It develops after organogenesis and could be caused by kinking of an artery during rotation, an embolus, amniocentesis, volvulus, intussusception or snaring at the umbilical ring. Polyhydramnios is the 1st symptom in about one third of the cases. Diagnosis can be confirmed by fetography or ultrasonography. The latter is preferred because of its non-invasivity. In amniotic fluid, high levels of bile salts (up to 30 times the normal level) were described in combination with atresia of the small bowel. A diminished dissacharidase activity is also ascribed to it. Most of the time the diagnosis is suspected after birth on the basis symptoms such as a gastric aspirate of more than 25 cubic cm, bile vomiting within a few hours, absence of meconium stool or distension of the abdomen. It can be confirmed by X-ray examination. The therapy of choice is liberal resection of the atretic part, because of the reduced bloodsupply of the adjacent bowel part. The mortality rate is about 12%. It is influenced in a negative way by restricted length of the remaining bowel, low birthweight, other congenital malformations, meconium peritonitis and a diagnostic delay of several days until diagnosis. Four other cases are described in the literature, in which the diagnosis was suspected antenatally by ultrasonography. The proper management during pregnancy cannot be extracted from these data. The benefit of antenatal diagnosis in the awareness it affords the surgeon at birth. With ultrasonography many congenital malformations antenatally can be detected. A discussion on what to do in such cases would be useful.