Maternal small-bowel volvulus hindered by prodromal labor
© Springer-Verlag 2007
Received: 22 April 2007
Accepted: 4 July 2007
Published: 16 August 2007
Small-bowel volvulus is a rare but accounts for 25% of the intestinal obstruction in pregnant women. Pregnancy and labor mask early signs and symptoms, leading to delay in diagnosis and increased morbidity. This report describes a case with bowel volvulus masked by early labor that underwent 330-cm resection of small intestine and gave a live infant.
Intestinal obstruction is a rare but serious complication of pregnancy, with significant maternal and fetal mortality; the incidence ranges from 1:1,500 to 1:66,000 deliveries [1–3] Small-bowel volvulus accounts for 25% of the intestinal obstruction in pregnant women but only 3–5% in nonpregnant women. Symptoms, including abdominal cramps and vomiting, are usually attributed to the normal discomforts of pregnancy and labor, resulting in delayed diagnosis [4, 5]. Here we report a case of ileal volvulus that occurred at term treated with wide bowel resection.
A large amount of ascites had been noted upon entering the peritoneal cavity, and subsequent examination of the abdominal cavity revealed a large amount of dusky, infarcted, and necrotic small bowel (Fig. 1b). A complete volvulus of dilated small bowel about its mesentery was identified. After detorsion, the gangrenous segment was covered with warm packing, and the team waited for re-oxygenation. However, it was decided to proceed to a resection of all gangrenous midgut segment (330 cm), starting from jejunum, 120 cm after the ligament of Treiz, including the ileum up to 110 cm before the ileocecum. Jejunoileostomy was performed. She had total parenteral feeding until the 14th postoperative day and started oral feeding thereafter.
The incidence of volvulus has been shown to increase with increasing gestation . Obstruction occurs most frequently at times of rapid increases in uterine size (between 16 and 20 weeks and 32 and 36 weeks). In some cases, such as ours, there is an increase in occurrence at term because of a contraction-like change in uterine size. The intestinal volvulus resulting in closed-loop obstruction may cause vascular compromise acutely, thus necessitating emergency surgical intervention. Abdominal distension and pain are the symptoms usually seen in patients who have intestinal obstruction in pregnancy. These symptoms appear whatever the etiologic cause is. Pregnancy and labor mask early signs and symptoms, leading to delay in diagnosis and increased morbidity . In our patient, 37 weeks’ gestation might have superimposed on labor onset and contributed to intestinal compromise. In retrospect, our patient presented with an early sign of small bowel obstruction and irregular cramping, which was believed consistent with prodromal labor. She had no history of emesis, fever, or localized abdominal pain, which usually are seen with infracted bowel. Surgical evaluation must be used liberally because medical and conservative treatment methods have less effect in pregnants than in normal population . As in our case, partial resection may be needed. Cesarean section is the choice for giving birth, as it gives a chance for the surgical evaluation of obstruction. The delay from presentation to definitive management continues to result in significant morbidity and mortality.
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