Perinatal/Neonatal Case Presentation &&&&&&&&&&&&&& When is Meconium-Stained Cord Actually Bile-Stained Cord? Case Report and Literature Review P. Vijayakumar did not grow any organism. Following an uneventful recovery, he THHG Koh was discharged home on day 6. DISCUSSION It is reasonable to assume that an umbilical cord stained green is due to the Amniotic fluid can be stained green by bile pigments if the fetus baby having passed meconium in utero. We describe a newborn baby in has hemolytic disease, passes meconium, or vomits bile.2 In 1972, whom there was a delay in diagnosing an imperforate anus because the the first reported case of vomiting in utero was a neonate with an baby’s umbilical cord was stained green with bile and it was assumed that atretic jejunum.2 The obstetrician had diagnosed hydramnios with the baby had passed meconium in utero. ‘‘meconium-stained liquor.’’ After birth, a small catheter inserted Journal of Perinatology 2001; 21:467 – 468. into the rectum dislodged some sticky white meconium with no lanugo hair. Another earlier report, in 1973, described a mother as having ‘‘golden liquor amnii’’ when the fore waters were ruptured.3 She delivered a live 36-week-old baby who had an CASE REPORT open 6-cm-diameter enterocoele containing stomach, small A term male neonate with a birthweight of 4.22 kg was born to a intestine, and half of the large bowel. The defect was judged too 21-year primigravida woman by spontaneous vaginal delivery. large for surgical correction. Williams et al.4 described a baby Antenatal period was uneventful. At delivery, the amniotic fluid was with congenital jejunal and ileal atresia. There was meconium- noted to be ‘‘meconium-stained.’’ There was no polyhydramnios. like staining of the amniotic fluid, which the authors believed At birth, the baby was otherwise well with no respiratory distress was probably due to fetal regurgitation or vomiting. Two other and had Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. reports in 1988 described green-amniotic fluid in five babies due The pediatrician was notified at 12 hours of age as the baby had to bilious vomiting in utero secondary to intestinal obstruction.5,6 vomited small quantities of brownish green fluid and was feeding In three cases, the babies were seen by a pediatric team, one poorly in the postnatal ward. The baby was not jaundiced and before discharge and all three before transfer to a regional general examination was normal. The abdomen was non-tender neonatal unit where the diagnosis of bowel obstruction was with sparse bowel sounds present. The umbilical cord was noted to made.5 The authors concluded that large volumes of green liquid be ‘‘meconium-stained’’ but without staining of the fingernails. obtained from the stomach suggest an intestinal obstruction and No respiratory distress was apparent. Antibiotics were commenced not in utero passage of meconium.6 In 1994, Akindele reported a after collecting blood cultures; full blood count and biochemistry female pre-term infant delivered to a teenage mother who had including blood gases were normal. A saline gastric lavage was fresh ‘‘meconium-stained’’ amniotic fluid during labour. At given for the possibility of meconium gastritis, and orogastric feeds resuscitation, the baby had copious amount of greenish effluent were continued. The baby continued to vomit small amounts of removed from the pharynx and stomach. The baby was later slightly green-stained milk. Feedings were discontinued and diagnosed to have ileal atresia; the ‘‘meconium-stained’’ intravenous fluid administration begun. A repeat clinical amniotic fluid due to in utero bilious vomiting, secondary to the examination at 29 hours revealed an imperforate anus. The intestinal obstruction. clinical finding was confirmed by an invertogram showing dilated In our case we believe that it was initially reasonable to loops of large bowels and a low imperforate anus. No fistula was assume that the baby had anal patency in view of the history of noted when anoplasty was performed on day 2. The blood cultures ‘‘meconium-stained’’ amniotic fluid and especially when the umbilical cord was also stained green. Our case is unusual in two main ways. All the previous reports were bowel obstructions Department of Neonatology, Kirwan Hospital for Women, Thuringowa, Great Barrier Reef, Townsville, QLD, Australia. proximal to the rectum and none of the previous cases described greenish staining of the umbilical cords. Meconium stained Address correspondence and reprint requests to THHG Koh, Department of Neonatology, Kirwan Hospital for Women, Thuringowa, Great Barrier Reef, Townsville, QLD 4817, Australia. amniotic fluid is observed at the time of delivery in 9 – 10% of the Journal of Perinatology 2001; 21:467 – 468 # 2001 Nature Publishing Group All rights reserved. 0743-8346/01 $17 www.nature.com/jp 467 Vijayakumar and Koh When is Meconium-Stained Cord Bile-Stained Cord pregnancies, but in one quarter of these no other evidence of early diagnosis, prompt and effective treatment and a better hypoxia is found.8,9 Fetal bowel peristalsis has been reported as outcome. early as 8 weeks of gestation.10 There is however, good evidence to suggest that fetal defecation is a routine physiological event in early and mid pregnancy.11 Abramovitch and Gray studied 31 Acknowledgment aborted human fetuses between 14 and 27 weeks gestation. By We thank Harry Stalewski for his surgical involvement. making the assumption that the presence of anal meconium signified that defecation has taken place the authors concluded that the fetus routinely defecates in utero until 16 weeks gestation References and finally ceases to defecate by 18–20 weeks.12 Also, infants born 1. Wiswell TE, Fuloria M. Management of meconium-stained amniotic fluid. with an anorectal malformation usually have an abnormally large Clin Perinatol 1999;26(3):659–68 (Sep). dilated rectosigmoid portion of the distal bowel full of meconium, 2. Shrand H. Vomiting in utero with intestinal atresia. Pediatrics 1972;49: 767–8. which suggests the prevention of fetal defecation in utero.11 Hence, 3. Daw E. Golden liquor amnii. Lancet 1973;1(7794):109. we assume that the mechanism of in utero vomiting associated 4. Williams J, Zakut H, Cohen D, Nissan S. Meconium-like staining of amniotic with imperforate anus is similar to that due to small bowel fluid due to high fetal intestinal obstruction. Case report. Br J Obstet Gynaecol obstruction. We believe that this is the first reported case of a 1978;85(9):713–4. greenish-stained umbilical cord due to bile rather than 5. Griffiths DM, Burge DM. When is meconium-stained liquor actually bile- meconium. stained vomit? Arch Dis Child 1988;63(2):201–2. Normally all newborn babies are examined twice during the first 6. Archer N. When is meconium-stained liquor actually bile-stained vomit? day of life; once immediately after birth for major abnormalities by Arch Dis Child 1988;63(8):999 (Aug). the midwife and a second examination by the junior doctor the 7. Akindele JA. Intestinal bilious vomiting — an unusual presentation of following day.13 Our experience serves as a reminder that major intestinal atresia in the newborn. Afr J Med Sci 1994;23:193–4. anomalies can still be missed in spite of repeated newborn checks. 8. Desmond MM, Moore J, Lindley JE, Brown CB. Meconium staining of the Our case highlights three important points. The first is the need to amniotic fluid. A marker of fetal hypoxia. Obstet Gynecol 1957;9:91–103. examine the anus in a newborn baby even when the history and 9. Kaplan C. Placental pathology for the nineties. Pathol Ann 1993;28:15–72. 10. Grand RJ, Watkins JB, Torti FM. Development of the human gastrointestinal clinical finding are suggestive of the baby having ‘‘passed tract. Gastroenterology 1976;70:790–810. meconium’’ in utero. A second message is that greenish staining of 11. Kimble RM, Trudenger B, Cass D. Fetal defecation: is it a normal the umbilical cord could be due to bile secondary to in utero bilious physiological process? J Paediatr Child Health 1999;35:116–9. vomiting and not necessarily due to meconium. The third one is 12. Abramovitch DR, Gray ES. Physiological fetal defecation in mid pregnancy. that in utero bilious vomiting could result from both upper and Obstet Gynecol 1982;60:294–6. lower bowel obstructions. The lessons from our case may result in 13. Koh THHG. Combining the two neonatal examinations. BMJ 1999;319:53. 468 Journal of Perinatology 2001; 21:467 – 468.