Volvulus in pregnancy

Analysis of acute abdomen case due to volvulus after laparotomy during pregnancy

 

 

    Puska Primi Ardini

Fetomaternal Divison

Obstetric and Gynecology Department

 Dr. Soeradji Tirtonegoro General Hospital

Klaten – Central Java

 

  Background                                                     Acute abdomen during pregnancy remains one of the most challenging diagnostic and therapeutic dillemas today. Despite technical advances in case diagnosis, preoperative diagnosis of surgical acute abdomen during pregnancy is still inaccurate. Laboratory parameters are not specific and often altered as  a physiologic of pregnancy. Volvulus of the small bowel, although being rare, carries a high risk of strangulation and ischemic necrosis. Preoperative dignosis is difficult and may be complicated by pregnancy, labor and the post cesarean-section state. Delay in diagnosis and surgical intervention increase morbidity and mortality rates.   Case report A 20-year- old primigravida woman, 8 month pregnant, came to emergency room of Dr. Soeradji Tirtonegoro General Hospital Klaten, with chief complain of colicky abdominal pain. Sign of labor such as bloody show, regular contraction, and dilatation of cervix didn’t find yet. She had laparatomy exploratory 4 monts ago when her pregnant was in 19 weeks of gestational age. She had crashed, then her radius-ulna was fratured, and then because of the trauma she also had laparotomy. The wedge excision simple suture on indication acute abdomen and internal fixation of her fracture was perfomed. The general condition of this time, she looked ill, but the vital sign was in normal limit. Ultrasonography scaning to evaluate her fetus was done. A singletone baby with good examination on amniotic fluid and placenta was detect. There is no sign of intrauterine fetal growth after her first operation. Formerly she was diagnosed as gastritis with differential diagnosis was ureter colic, but because she felt more severe pain, then it was established as generalised peritonitis due to appendicitis. In clinical examination temperature was 37⁰C, pulse rate and respiratory rate were 90 and 24 bpm, the blood pressure was 110/70 mmHg. Abdominal examination revealed generalized pain due to peritoneal irritation. Haemoglobine level was 11.2 mg/dl, creatinin was 0.58 mg/dl, sodium and potassium were 130 and 3.8 mmol/L. White blood cell count was 11.900 mL. During operation, ileal volvulus and ileal necrotic were found. Because it was considered that operation will last longer, so it’s decided to perfom emergency cesarean section first. Female baby was born, with 1950 grams weight, length 40 cm, AS 3/4. After that, the anastomosis resection ileo-ileal end to end was perfomed. Post operative patient was transfered to ICU.   Discussion Volvulus, occuring most frequently in the sigmoid and very rare in the small bowel, carries a high risk of strangulation and ischemic necrosis. It is ussualy caused by the rotation of a loop  of small intestine around an adhesion band or stroma. Primary small bowel volvulus occurs without any predisposing cause. Early diagnosis and management is essential to avoid infarction of bowel. The condition may result in a maternal mortality rate of 6 -20% and a fetal loss in 26 – 50% of the cases even with a delay of 24 hours. Although volvulus is a very rare condition in pregnancy, most cause of obstruction secondary to small bowel volvulus occur in the third trimester or puerperium. Non obstetrics surgery in pregnant women had purposed to save mother life and control fetal from risk with anaesthetic agent and surgery. Decision to do cesarean section depends on many factors such as gestational age and maternal condition. In case which transabdominal fetal monitoring could not be done, vaginal doppler probe could be an alternative (Carvalho, 2006) It is noticeable that our young patient was in third trimester of pregnancy with previous history of abdominal surgery when the gestational age was 19 weeks. The cardinal presenting symptom was generalized abdominal pain. Patient had nausea without vomiting and reported a normal bowel habit. Fortunately she was young and surived after surgical intervention although she need ICU admission for about three days. The onset of symptoms is often rapid with severe central abdominal pain being exceedingly common, suggesting that the initial presentation may result from mesenteric torsion rather than luminal obstruction. Elective non obstetric surgery should be delayed until postpartum. At emergency surgery setting, the operation should proceed with optimal anaesthetic for mother modified by considerations for maternal physiologic changes and fetal well being. Intraoperative and postoperative fetal monitoring may be useful. At first trimester, non obstetrics surgery should be delayed until mid gestation if there is no or minimal increased risk to mother. But if there is greater than minimal increased risk to mother, proceed with surgery. At third trimester, cesarean section delivery before major operation is usually recommended. If possible, it’s better to delay operation until 48 hours for lung maturation and consult to perinatology to prepare perinatal case. Non-obstetrical acute abdomen during pregnancy must be diagnosed early and accurately, because surgical treatment is indicated in most cases, as in nonpregnant women.  Nevertheless diagnosis of acute abdomen during pregnancy is difficult due to:

1. Expanding uterus dislocates other intraabdominal organs and thus makes physical examination very difficult
2. High prevalence of nausea, vomiting, and abdominal pain in the normal obstetric population
3. General relutance to operate unnecessarily a gravid patient

  Preoperative diagnosis is difficult and may be complicated by pregnancy, labor and the post cesarean section state. It is supposed that gradual enlargement of the uterus in pregnancy causes partial obstruction of the small bowel with proximal distension and torsion at the point of fixation or increase in uterine size in the third trimester and sudden decrease during the puerpurium may predispose to small bowel volvulus Delay in diagnosis and surgical intervention increases morbidity and mortality rate. Goals for treatment of small bowel volvulus should include physician awareness of this uncommon diagnosis, accurate workup, and advanced surgical intervention. Therefore, close cooperation between surgen and obstetrician is obligatory. The failure to perform an exploratory laparotomy cannot be justified but especially in early onset of disease, laparoscopic approach may be a safe, feasible, and favorable option for correct diagnosis and appropriate treatment. Retrospectively reviewing the case we presume if in early stage of her condition, precise evaluation was perfomed, laparoscopy could be helpful in diagnosis and treatment instead of this extensive operation.