Lin et al.

against the abdominal wall will reduce the amount of fluid in the cul-de-sac and diminish the discernible contrast.

Cooperation between the operating surgeon and the ultrasound operator is essential. The ultrasound op­erator should constantly inform the operating surgeon of the position of the resectoscope in order to avoid any accidental injury to the uterine wall. Both preop­erative and postoperative ultrasonograms or hystero­salpingograms should be obtained to assure complete resection of myomas.

The advantage of using the pediatric resectoscope is that accurate observations of the intrauterine condition can be made without a need for cervical dilation. This procedure is difficult to perform with an adult-type resectoscope. Dilation of the cervical canal may cause uterine bleeding and blood clotting; it can also cause

February 1987 Am J Obstet Gynecol

subsequent uterine contraction, which will interrupt operation. The three-contrasts method of ultrasonog­raphy makes it possible to monitor the posterior uterine wall, the submucous myoma, and the scope and thus enhances the safety of transcervical operations.

REFERENCES

1. Neuwirth RS. A new technique for and additional expe­rience with hysteroscopic resection of submucous fibroids. AM j 0BSTET GYNECOL 1978;131:91-4.

2. DeCherney A, Polan ML. Hysteroscopic management of intrauterine lesions and intractable uterine bleeding. Ob­stet Gynecol 1983;61:392-7.

3. Daly DC, Walters CA, Soto-Albors CE, Riddick DH. Hys­teroscopic metroplasty: surgical technique and obstetric outcome. Fertil Steril l 983;39:623-8.

4. Romero R, CopelJA,Jeanty P, Reece EA, Reiss R, Hobbins JC. Sonographic monitoring to guide the performance of postabortal uterine curettage. AM J 0BSTET GYNECOL 1985;151:51-3.

Prenatal ultrasonic diagnosis of multiple bowel atresias

M. Amanda Skoll, M.D., Gerald P. Marquette, M.D., and Emily F. Hamilton, M.D.

Montreal, Quebec, Canada

This case illustrates the course of an obstructive process through spontaneous perforation resulting in decompression of dilated bowel loops. The resulting meconium peritonitis appeared as fetal ascites. Postnatal investigations and Iaparotomy confirmed the diagnosis of a rare form of multiple congenital atresias of the bowel. (AM J OBSTET GYNECOL 1987;156:472-3.)

Key words: Prenatal diagnosis, bowel atresia, ascites, ultrasound

In this report, we describe a case of multiple atresias involving segments of the fetal gastrointestinal tract from stomach to rectum, with spontaneous perforation and subsequent meconium peritonitis.

Case report Mrs. P. S., a 19-year-old primigravid woman, under­

went ultrasound examination at 21 weeks' gestation that revealed multiple large fluid-filled loops of dilated bowel occupying the upper anterior region of the fetal abdominal cavity (Fig. 1). The amniotic fluid volume was normal and no other structural abnormalities were found.

Follow-up scanning from 25 to 28 weeks' gestation

From the Department of Obstetrics and Gynecology, Royal Victoria Hospital and McGill University.

Received for publication March 5, 1986; revised June 12, 1986; accepted August 12, 1986.

Reprint requests: Dr. Gerald P. Marquette, Royal Victoria Hospital, Women's Pavilion, F4.29, 687 Pine Ave. West, Montreal, Quebec, Canada H3A JAi.

472

Fig. 1. Sonogram at 21 weeks' gestation. Dilated loop of bowel (arrowhead) in the upper part of the abdomen.

Volume 156 Number 2

showed a reduction in the bowel distention and the appearance of fetal ascites (Fig. 2). However, from 28 to 33 weeks, an increase in dilatation became apparent and was accompanied by gradual disappearance of the ascites. Concurrent with resolution of the ascitic fluid, a calcified collection became evident in the right lower quadrant and remained constant.

At 35517 weeks' gestation, the patient was delivered spontaneously of a 2400 gm male infant. The baby had significant abdominal distention. Subsequent Iaparot­omy revealed numerous sites of atresia throughout the bowel. Beginning in the stomach, multiple septa di­vided the intestine into segments of 2 to 3 cm, and the calcified deposits that had been previously noted on ultrasound were entirely within the lumen.

Comment The presence of multiple distended loops of bowel

is compatible with a distal obstructive process. Fetal ascites in combination with other signs of bowel ob­struction suggests the occurrence of spontaneous per­foration with subsequent meconium peritonitis.' Most commonly, meconium peritonitis results from obstruc­tion secondary to meconium ileus or low atresia. In­traperitoneal calcifications have been described as a sequela of meconium peritonitis, due to the precipita­tion of tissue calcium by the fatty components of me­conium.'

In our case, the initial picture was compatible with proximal intestinal obstruction. ·However, the subse­quent appearance of ascites seemed to represent me­conium peritonitis, more in keeping with low obstruc­tion. Findings at laparotomy explained the ultrasound results by confirming both upper and lower bowel atre­sias. This rare condition2 is associated with pasty cal­cification within the bowel lumen.

Ultrasonic diagnosis of bowel atresia 473

Fig. 2. Sonogram at 25 weeks' gestation. Decreased dilatation of bowel loops with presence of ascites (arrowhead). Same level as Fig. !.

This is the first known reported case of multiple atre­sias of this type described on ultrasonography. It dem­onstrates that intra-abdominal calcifications may not always represent intraperitoneal deposits. It also pro­vides an example of the features of simultaneous upper and lower intestinal obstruction.

REFERENCES

I. Williams J, Nathan RD, Worthen NJ. Sonographic dem­onstration of the progression of meconium peritonitis. Ob­stet Gynecol 1976;47:618.

2. Guttmann FM, Braun P, Garance PH, et al. Multiple atre­sias and a new syndrome of hereditary multiple atresias involving the gastrointestinal tract from stomach to rectum. J Pediatr Surg 1973;8:633.