We report a case of a 32-year-old Gravida 5 Para 3 pregnant patient, referred for collaborative care with Maternal Fetal Medicine, Neonatology, and Pediatric Surgery due to an abnormal prenatal ultrasound with echogenic and dilated fetal bowel. She had adequate prenatal care with an outside facility, including a normal glucose tolerance test. Workup included cystic fibrosis carrier testing and non-invasive prenatal genetic screening which were negative. At 34 weeks 3/7 days, prenatal ultrasound showed estimated fetal abdominal circumference at 37.2 cm (99th percentile) and largest bowel loop diameter dilated to 4.9 cm. [Figure 1] The fetal largest abdominal diameter, when measured retrospectively on prenatal images, was 13.4 cm. The amniotic fluid index was 20.2 cm. All teams agreed that, in this case, the abdomen should be considered compressible and not a contraindication to vaginal delivery.

At 36 weeks and 1/7 day, the patient presented to labor and delivery with preterm prelabor rupture of membranes (PPROM). The admission ultrasound was notable for fetal abdominal circumference of 46 cm and 14.0 cm at largest diameter, with stable bowel loops dilated to 4.8 cm. The patient had 3 prior vaginal deliveries, with the largest infant weighing 3.572 kg, the estimated fetal weight on admission was 3.8 kg. The patient was counseled on the fetus’ abdominal distention and the consulting services recommended labor, as the abdomen was considered compressible. The patient agreed to a vaginal delivery.

The patient’s labor progressed appropriately with oxytocin induction. She progressed to complete cervical dilation within 8 hours from admission. During the second stage of labor, the fetal head was delivered with a single maternal expulsive effort, but the remaining body did not deliver. Initially, a shoulder dystocia was presumed, but the fetal shoulders freely rotated without evidence of impacted shoulder. Episiotomy was performed to allow adequate room for examination. The posterior arm was delivered which allowed the anterior shoulder to deliver, but the delivering clinician was able to palpate in situ and confirmed that the abdominal girth remained above the pelvic inlet. Vaginal delivery efforts were halted. At this time, the posterior arm was replaced and the fetal head was elevated and supported as the patient was moved to the operating room.

Under general anesthesia, an abdominal rescue was performed via primary classical cesarean section. The fetal head could not be completely replaced into the vaginal canal to complete the Zavanelli maneuver until the hysterotomy was performed. Total time from vaginal delivery of the fetal head until abdominal birth was 12 minutes. A male infant weighing 3.17 kg was born with APGAR scores of 1, 4, and 7 at one, five, and ten minutes, respectively. The neonatal abdomen was distended, taut, and non-compressible upon neonatal examination. [Figure 2]. Cord blood gas pH studies were notable for an arterial pH of 7.0 and a base excess of -12.2 mmol/L. The neonate was intubated due to respiratory distress and transferred to the local children’s hospital for surgery. The neonate underwent exploratory laparotomy and had a large meconium cyst containing nearly 1 liter of fluid. There were several blind ending segments of the bowel. An end ileostomy was performed and later, two abdominal drains were placed. Newborn screening was initially abnormal for cystic fibrosis, but microarray was normal for genotypic male. Two months after delivery, he underwent a tapering jejunoplasty and was ultimately diagnosed with jejunal atresia. Most recently, the infant is in the care of his parents at home.