Acute abdomen in the 3rd trimester: small intestine volvulus in pregnancy

Introduction Volvulus in pregnancy is rare and difficult to diagnose. The incidence is approximately 1/1,500-66,000 of pregnancies [1]. The most common symptoms are abdominal pain, nausea and vomiting and are therefore non-specific. Obstructions in pregnancy arise as part of a volvulus. Other causes include adhesions, hernias and malignancies [1] [4]. The localization can be in the stomach, duodenum, small intestine, appendix, colon or sigmoid region1. A sigmoid volvulus is most common (about 25% to 44% of cases). It"s a surgical emergency – timely intervention is essential to reduce maternal and fetal damage (maternal mortality rate is 6-20% and infant mortality rate is 20-26%) [3]. Perforation, peritonitis and sepsis are the most common maternal complication, premature birth, intrauterine death and neonatal sepsis – are fetal complications.

The case Emergency admission of a 30-year-old IG/0P in the 36+0 week of gestation with upper abdominal pain for about 5 hours and vomiting with a history of chronic constipation with daily use of Movicol and clysma. Patients history: uneventful course of pregnancy, a laparoscopy for endometriosis, a Colonoscopy by sigma elongatum. Admission findings: normal fetal sonography, normal maternal kidney and upper abdominal sonography, normal lab readings with no evidence of a HELLP syndrome. The internal co-assessment confirmed a coprostasis. Due to persistent pain despite an adequate analgesia, the prim. C-section in general anesthesia was indicated. Intraoperative detection of small bowel torsion with ischemia. Co-assessment by the surgical colleagues with the decision to leave the affected part of the small intestine in place and planning a second-look operation. Insertion of a Vac – pump. On the following day the general condition of the patient worsened. The affected portion of the small bowel was resected with an end-to-end anastomosis due to a small bowel ischemia over a distance of about 100 cm. A discharge was possible after a total of 19 days.

Discussion Small bowel volvulus in pregnancy is rare. It requires a multidisciplinary care. In the case of upper abdominal pain, nausea, vomiting and normal lab fidings, volvulus must be considered in the differential diagnosis. Early diagnosis and surgical therapy are crucial to reduce maternal and fetal complications. If the findings are unclear, MRI imaging can be considered [2].

 

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• References

• 1 Connolly MM. et al. Bowel obstruction in pregnancy
• 2 Chong E. et al. Midgut Volvulus: A Rare but Fatal Cause of Abdominal Pain in Pregnancy – How Can We Diagnose and Prevent Mortality?
• 3 Cong Q. et al. Small bowel volvulus in mid and late pregnancy: can early diagnosis be established to avoid catastrophic outcomes? PMCID: PMC4276242, PMID: 25550984.
• 4 Webster P.. et al. Small bowel obstruction in pregnancy is a complex surgical problem with a high risk of fetal loss

Publication History

Article published online:
15 November 2023