This case presentation discusses the diagnosis and management of congenital duodenal atresia in a 35-year-old pregnant patient. Prenatal ultrasound revealed signs of duodenal atresia including polyhydramnios. After being admitted in preterm labor at 34 weeks, the patient delivered a baby boy with duodenal atresia who underwent surgery on postnatal day 4. Duodenal atresia results from failure of embryonic development and is often associated with other anomalies. Prenatal diagnosis allows delivery at a center prepared to care for the newborn.

1. 
CASE PRESENTATION

2. Objectives:
 Present a case of congenital duodenal atresia
 Discuss the embryology, clinical presentation, and
diagnosis of the malformation
 Give recommendations on obstetrical antenatal
and intrapartal management of patients carrying
fetuses with such malformations

3. Introduction
 Duodenal atresia is the most common cause of fetal
small bowel lumen obstruction
 Duodenal atresia is lack of revacuolization during
the solid-core stage of embryonic intestinal
development

4. 4

THE CASE

5. General information
 35 years old
G3P1(1011)
 Single
 Filipino
 Roman Catholic
 Government Employee (Nursing Attendant at Sta. Ana
Hospital)
 Was referred to High Risk Clinic on 2/14/17 for co-
management

6. Menstrual History
 LMP: unsure
 AOG: 32 5/7 weeks by EUTZ
 EDC: April 6, 2017

7. OB History
 Gravida 3 Para 1 (1011)
G1 2003 Full term boy NSD Alive, No
complications
G2 2015 D&C Early Embryonic Demise
(8weeks)
G3 Present pregnancy

8. Prenatal History
1st trimester:
 No PNCU
 Folic acid 5 mg OD

9. Prenatal History
2nd trimester:
 PNCU: Ospital ng Maynila(2X)
 CBC: Hgb:128
Hct:0.37
WBC:15.30
Platelets: 340
 UA: pus cells-0-2
RBC-0-1

10. Prenatal History
2nd trimester:
 HBsAg: non-reactive
 RPR: non-reactive
 HIV:non-reactive

11. Prenatal History
2nd trimester:
 UTZ: Sta. Ana Hospital (11/25/17)
 SLIUP, Cephalic, 21 Weeks and 1 day by Fetal
Biometry, Anterior placenta, Grade 1,
Normohydramnios, SEFW:314g
 Patient was given MVTS and FeSO4 with Folic Acid

12. Prenatal History
3rd trimester:
 PNCU: Dr. Jose Fabella Memorial Hospital (at 31 4/7
weeks)
 75 g OGTT: FBS-87.28
1st hour-153.65
2nd hour-123.02

13. UTZ (2/09/17) DJFMH-Women’s Clinic
at around 32 Weeks Gestation
UTZ result:
Dr. Jose Fabella Memorial Hospital

14. UTZ (2/09/17) DJFMH-Women’s
Clinic

15. UTZ (2/09/17) DJFMH-Women’s
Clinic

16. UTZ (2/09/17) DJFMH-Women’s Clinic

17. UTZ (2/09/17) DJFMH-Women’s Clinic
Congenital Anomaly Scan:
Single live intrauterine pregnancy
cephalic presentation
31 5/7 weeks by biometry
AGA (2080 gms)
Anterior high lying placenta grade I
Polyhydramnios (35.06)
Consider Duodenal Atresia

18. Past Medical History
(-) Asthma (-) diabetes (-) hypertension
(-) previous hospitalization

19. Family History
(+) asthma-Maternal aunt
(-) diabetes
(+) hypertension-Father
(-) cancer

20. Personal and Social History
(-) smoker
(-) alcoholic beverage drinker
(-) allergies to food and drugs

21. Physical Examination
 conscious, coherent, oriented to 3 spheres
 BP 110/80 CR 81 RR 19 T 36.9
 HEENT: Pink palperbral conjunctivae, anicteric sclerae
 Chest and Lungs: SCE, NR, RR
 Abdomen: globular FH: 34 cm FHT 130 RLQ
 No gross deformities
 IE: cervix soft closed, uneffaced, (-) BOW cephalic st-3

22. 22
WORKING DIAGNOSIS:
Gravida 3 Para 1 (1011)
Pregnancy Uterine 32 5/7 weeks of gestation by EUTZ
Cephalic not in labor
Congenital Anomaly (Duodenal Atresia)
Polyhydramnios

23. Recommendation:
 Dexamethasone
 Fetal well-being studies
 Biometry every 2 weeks to monitor growth
 BPS with NST weekly
 WOF signs of Preterm Labor
 Fetal echocardiography
 Refer to newborn medicine and pediatric surgeon prior to
delivery

24. Long Term Plan:
 To bring pregnancy to term
 Karyotyping of the Newborn
 Mode of Delivery: Normal Spontaneous Delivery

25. Emergency Room (34 5/7 weeks
gestation)
 Chief Complaint:
labor pains

26. Physical Examination
 conscious, coherent, oriented
 BP 110/70 CR 82 RR 19 T 36.6
 HEENT: Pink palperbral conjunctivae, anicteric sclerae
 Chest and Lungs: SCE, NR, RR
 Abdomen: globular FH: 30 cm FHT 140 RLQ
 No gross deformities
 IE: cervix soft 5 cm dilated, 50% effaced, (-) BOW, clear AF,
cephalic st-3

27. Admitting Diagnosis (2/28/17)
G3P2(1011)
Pregnancy Uterine 34 5/7 Weeks by EUTZ
Cephalic in Preterm Labor
Congenital Anomaly (Duodenal Atresia)
Polyhydramnios

28. Course in the Ward(2/28/17)
 Almost 1 hour after admission, patient delivered via
Normal Spontaneous Delivery to an alive preterm
boy 35 Weeks by BS (2160g, 48 cm) AS 8,9
 Baby was admitted at the NICU with the ff.
diagnosis: t/c Trisomy 21, Intestinal Obstruction
2°to Duodenal Atresia, Congenital Heart
Disease(PDA, stretched PFO, TR mild, MR mild)

29. Course in the Ward(3/2/17)
 On the 4th HD, baby underwent duodeno-
duodenostomy

30. 30

DISCUSSION

31. Duodenal Atresia
 Congenital birth defect wherein the 1st part of the
small intestines, known as the duodenum fails to
develop
 Duodenal atresias occur in approximately 1/5,000-
10,000 live births
 Incidence: associated with Trisomy 21 in 30-50%
:isolated anomaly in 30-52% of cases

32. Duodenal Atresia
 The exact etiology is still unknown
 Equal male-to-female predisposition
 No racial predilection
 Recurrence is not known to be increased

33. Duodenal Atresia
Nuchal Translucency Trisomy 21
33

34. Duodenal Atresia
Double-bubble sign Polyhydramnios
34

35. Embryogenesis of Duodenal Atresia

36. Embryogenesis of Duodenal Atresia

37. Embryogenesis of Duodenal Atresia

38. Embryogenesis of Duodenal Atresia

39. Embryogenesis of Duodenal Atresia-
Type 1 Defect

40. Embryogenesis of Duodenal Atresia-
Type 2 Defect

41. Embryogenesis of Duodenal Atresia-
Type 3 Defect

42. 42
Associated anomalies:
: Trisomy 21 (30-50%)
: Polyhydramnios
: Congenital heart defects(ASD and VSD)
: Malrotation
: Meconium ileus and peritonitis
: Volvulus
: Annular pancreas
: Esophageal atresia
: Genitourinary malformations
: Anorectal atresia
: Ventral wall defects and skeletal defects
1 Creasy and Resnik’s Maternal Fetal Medicine

43. 43
Antenatal Monitoring
 Congenital Anatomy Scan
 Amniocentesis for karyotyping, cystic fibrosis status
 Fetal Echocardiography for cardiac malformations
 MRI to determine level of obstruction
 Fetal NST and Biophysical profile (or both) in the 3rd
trimester
 Newborn medicine and Pediatric surgery consult

44. Prognosis:
 Overall prognosis depends on the presence of associated
anomalies particularly aneuploidy
 Survival data improved from 60%(1960s-1970s) to 90%-
100%(1990s-2000s)
 Chronic total parenteral nutrition may lead to cholestasis
and subsequent liver damage
Creasy and Resnik’s Maternal Fetal Medicine

45. 45
Obstetric Management
 Mode of delivery:
 Delivery in a tertiary care hospital is recommended
 Therapeutic amnioreduction may reduce the risk of
preterm labor, cord prolapse, and abruption with
rupture of membranes
 Cesarean delivery is reserved for obstetrics
indications
1 Creasy and Resnik’s Maternal Fetal Medicine

46. 46
Summary/Conclusion:
 Prenatal diagnosis provides the opportunity to plan
the delivery of a baby at a center where immediate
and definitive care can be provided.
 Pediatric surgeon, neonatologist should be readily
on standby once the baby is delivered
 Timely diagnosis and appropriate interventions may
lead to a favourable outcome

47. 
HAVE AN AWESOME DAY!