70 • PERINATOLOGY Vol 24 • No. 1 • May–Aug 2023 Discussion This full-term neonate presented with early ventilatory failure due to great abdominal distension without a clear cause at the time of birth. With macroscopic and microscopic findings of meconium peritonitis, he was taken to surgery immediately. This disease is a rare entity, with an incidence of 1 in 30,000 to 35,000 live births. If this condition is diagnosed prenatally, the mother–fetus pair should be advised for perinatal follow-up. Neonatologists and pediatric surgeons should be consulted for early care. Prenatal diagnosis and early interdisciplinary management could prevent the episodes of hypoxia and improve the results. However, this could not be proven.3 It is expected that the morbidity and mortality rates can be reduced with a prenatal diagnosis and adequate immediate postnatal management. This neonate recovered well and showed good improvement. However, this condition has a mortality rate of up to 60% without treatment or with late treatment, and it can also result in more comorbidities. Therefore, we believe that patients without a prenatal diagnosis should be referred soon for early comprehensive treatment. The main cause for this condition indeed could be a mechanical event; however, prenatal evaluation of other related causes such as perinatal infection by cytomegalovirus and parvovirus B19 could be a valid recommendation, as these serologies are not routine tests in prenatal care.4 Other frequent associative factors for this condition should also be explored, for example, prenatal genetic study of CF, parents possibly being the carriers of some related mutation, suspicion of specific mutations according to the ethnic group to which they belong, and the possibility of the stratifying risk that neonates suffer from the disease. The disease can be suspected when prenatal ultrasound findings show conditions such as intestinal echogenicity, intestinal loop dilation, and absence of visualization of the fetal gallbladder, mainly in the second and third trimesters. Sonographic characteristics of fetal bowel obstruction are neither sensitive nor specific for CF; thus, the interpretation must include consideration of the risk of the fetus having CF.5 Patients with CF develop severe clinical conditions in future.6 Despite this approach, the etiology cannot be determined in almost 50% of patients.3 However, more studies on CF should be conducted. In our case study, the neonate has a rare mutation. Early clinical manifestations help suspect the disease.7 Further, prenatal predictors of this condition can help decide early postnatal intervention for the neonate. A systematic review and meta-analysis evaluated 244 patients with meconium peritonitis (whose prenatal ultrasound findings were suggestive of meconium peritonitis), of which 66.5% required surgical intervention. The conditions that necessitated neonatal surgery were meconium pseudocyst (OR [95% CI]: 6.75 [2.53– 18.01]), followed by intestinal dilation (OR [95% CI]: 4.17 [1.93–9.05]) and ascites (OR [95% CI]: 2.57 [1.07– 5.24]).1 Other findings such as fetal ascites and maternal conditions such as polyhydramnios and intrahepatic cholestasis were also associated with the need for early postnatal intervention.8 Prenatal ultrasound can identify most of these markers. In addition, fetal MRI can determine early intervention markers. A study of 35 fetuses with a prenatal diagnosis of meconium peritonitis, who underwent MRI, found that fetuses with intestinal dilatation and microcolon were the main markers of early postnatal intervention.9 However, in our study, ascites was not a determining marker of early postnatal intervention. These prenatal marker findings assisted in deciding the early postnatal intervention, which could help predict the need for early surgical intervention.10,11 Once the prenatal diagnosis of meconium peritonitis is confirmed and the risk is stratified, close followup should be done as there is a possibility of in utero scarring. Fetal well-being tests help decide whether the pregnancy should be terminated.12 It must be borne in mind that premature birth is associated with a worse prognosis.8 Although prenatal stratification helps decide the initial approach, 61.2% to 66% will require surgical intervention.1,8 Hence, such deliveries must happen in centers with pediatric surgeons and neonatologists. The clinical indications that require surgical intervention Alvarez Saenz MP, et al. Meconium Peritonitis Case Report
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