This case involves a forty-seven-year-old mother at thirty-one weeks gestation who delivered via cesarean section. The mother had a past medical history of chronic hypertension and diabetes mellitus. The patient experienced some painless vaginal bleeding the day of delivery, and she was later diagnosed with placenta previa. The previa spanned the majority of the internal Os, and therefore, the decision of an emergent cesarean section was made. Surfactant administration was carried out and empiric therapy for sepsis was begun.
A week later, the infant developed bradycardia and feeding difficulties. The following day, the patient developed hematemesis and the physical exam showed a firm distended abdomen. The resident physician ordered an abdominal x-ray, which showed necrotizing enterocolitis (NEC) with perforation. A repeat abdominal x-ray was ordered the following morning by the attending physician and was found to be consistent with the original showing NEC with pneumatosis. Pediatric surgery was then consulted and the patient was sent to the OR. The patient subsequently developed periventricular leukomalacia (PVL) and later died due to complications of sepsis.
Questions to the Pediatric Surgery expert and their responses
What are the general parameters for emergency surgery in the case of NEC or pneumoperitoneum?
Necrotizing enterocolitis (NEC) is one of the most common gastrointestinal emergencies in the newborn infant. It is a disorder characterized by ischemic necrosis of the intestinal mucosa, which is associated with inflammation, invasion of enteric gas forming organisms, and dissection of gas into the muscularis and portal venous system. The timing of surgical intervention in a critically ill infant requires considerable judgment, as one wishes to preserve as much bowel length as possible. An unstable patient, however, may not be able to tolerate the surgical procedure. Infants with NEC require surgical intervention when necrosis extends through the bowel wall and results in perforation. The decision to perform surgery is clear when pneumoperitoneum is recognized on the abdominal radiograph. No time should be wasted; the patient should be immediately taken to the OR to reduce the risk of severe sepsis and death.
About the expert
This qualified, board-certified surgeon is fellowship-trained in pediatric surgery. He has authored a vast body of publications and has pursued several major medical research projects. He currently holds an associate professorship at a major medical university.
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About the author
Dr. Faiza Jibril
Dr. Faiza Jibril has extensive clinical experience ranging from primary care in the United Kingdom, to pediatrics and child abuse prevention at Mount Sinai Hospital, to obstetrics in Cape Town, South Africa. Her post-graduate education centered on clinical research and medical ethics. Dr. Jibril is currently Head of Sales in the US and Canada for Chambers and Partners - a world leading legal ranking and insights intelligence company.
