1. CAROLINE BUCKLEY CASE OF THE YEAR

2. MATERNAL DETAILS 21 years old, primigravida O Rhesus Positive, antibody negative Rubella Immune, Hep B, HIV negative Non-smoker, no alcohol No significant past medical history, scans normal

3. LABOUR & DELIVERY Spontaneous onset of labour at 41+3 weeks Rupture of membranes 3 hours prior to delivery No pyrexia in labour, no offensive liquor Cephalic presentation, SVD Apgar scores 9 & 10 Birth weight 3.995kg

4. NEWBORN EXAMINATION Performed at nine hours of age No concerns Abdomen soft, not distended. Small soft ‘lump’, near umbilicus Not tender Well baby, normal movements and tone

5. ‘….can you come and have a look at this baby. I’m sure it’s nothing, it’s not urgent. She’s well, she’s feeding, but there’s just something that doesn’t feel right when I felt her abdomen…’ midwife, low dependency delivery unit

6. WHAT DO YOU THINK ? IS THERE ANYTHING YOU WOULD LIKE TO KNOW ?

7. WHAT DO WE WANT TO KNOW..? Pink, alert and active Feeding - formula via bottle, some mucousy vomits Bowels not opened yet (but nine hours old)

8. WHAT DO YOU THINK ? WHAT WOULD YOU LIKE TO DO ?

9. THINGS TO THINK ABOUT Review full history – ensure that no meconium was passed prior to delivery Examine notes for any evidence of polyhydramnios or other abnormalities on antenatal scans, e.g. dilated loops of bowel Anus appeared to be patent on examination

10. OUR PLAN… Continue to demand feed Observe closely, await passage of meconium Review in the morning – if passed meconium by then and remains well, can go home. Contact the neonatal team if any concerns…

11. …IN THE MORNING Overnight, baby had fed …. but bowels not opened ! Baby is now 18 hours of age

12. WHAT DO YOU THINK ? WHEN SHOULD YOU START TO BE CONCERNED ?

13. ON EXAMINATION… Baby awake, alert, rooting Abdomen now distended and tense Green bilious vomit as soon as baby handled

14. ABDOMINAL DISTENSION Can be moderate or extreme Suggests an intestinal obstruction or intra-abdominal mass

15. BILIOUS VOMITING IS ALWAYS PATHOLOGICAL NEVER IGNORE IT

16. INTESTINAL OBSTRUCTION Infant presents with some or all of the following features: Bile stained vomiting Abdominal distension Visible peristalsis Delayed passage of meconium Dehydration

17. CLASSIFICATION OF INTESTINAL OBSTRUCTION Classified depending on the site of the blockage (large or small bowel), or whether this is anatomical or functional Pyloric stenosis Duodenal obstruction Anorectal malformations Hirchsprungs disease Meconium ileus

18. OUR PLAN… Admit to the NNU immediately Nil by Mouth Nasogastric tube Abdominal x-ray IV fluids

19. ABDOMINAL X-RAY

20. meconium ileus

21. MECONIUM ILEUS Bowel obstruction caused by highly viscid meconium within the lumen Cystic Fibrosis (CF) is almost always the cause Around 15% of infants with CF will present in this way

22. MECONIUM ILEUS Clinical features: Antenatal history of echogenic bowel on USS Family history of CF or parental CF carrier status Most common site of obstruction is in the distal ileum Progressively worsening bilious vomiting Abdominal distension Palpable and sometimes visible bowel loops Palpable abdominal mass Failure to pass meconium

23. THEN WHAT HAPPENED… Baby transferred to the RVI urgently Bowel surgery performed that day – formation of a stoma Sweat test and genetic testing for Cystic Fibrosis …positive

24. INHERITANCE OF CYSTIC FIBROSIS

25. REMEMBER...! You would expect all babies to pass meconium within 24 hours of birth Bile stained vomiting is always pathological Abdominal distension might suggest an intestinal obstruction or intra-abdominal mass

26. THANK YOU FOR LISTENING !