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Indian Journal of Medical Sciences, Vol. 59, No. 7, July, 2005, pp. 317-319 Case Report Sigmoid volvulus complicating pregnancy De Utpal, Kamal De K. Department of Surgery, Burdwam Medical College, Burdwan, West Bengal Code Number: ms05048 ABSTRACT Sigmoid volvulus complicating pregnancy is an extremely rare complication with fewer than 76 cases reported in literature. We report a case of sigmoid volvulus complicating pregnancy. The sigmoid colon was resected and Hartman's colostomy was performed. The patient had a successful recovery. Aggressive resuscitation followed by early surgical intervention should be undertaken to reduce maternal and fetal morbidity and mortality.Keywords: pregnancy; volvulus INTRODUCTION Intestinal obstruction, complicating pregnancy is an extremely rare complication. Volvulus of sigmoid colon is the most common cause of intestinal obstruction complicating pregnancy, accounting for up to 44% of cases. [1] Since the initial report by Braun in 1885, less than 76 cases [Table - 1] have been reported in world literature. [2],[3],[4],[5],[6] We present a case report of sigmoid volvulus complicating pregnancy to emphasize the typical clinical presentation of the condition, its progressive nature and deleterious effect on the foetus and the importance of early intervention.Case report Twenty-one-year old, primigravida, presented during 24 weeks of an otherwise uneventful pregnancy with complaints of intermittent abdominal pain and worsening constipation since 3 days. She had no history of previous medical problems or prior abdominal surgery. On physical examination, patient was febrile. Per abdominal examination revealed generalized abdominal tenderness and huge abdominal distention. Bowel sounds were absent. Fetal heart sounds were absent at presentation. Per rectal examination revealed an empty rectum with rectal ballooning. Pervaginal examination revealed a closed cervix. Abdominal radiography performed after admission suggested sigmoid volvulus. Doppler ultrasonography of the abdomen revealed a dead fetus. After initial resuscitation with IV fluids and nasogastric suction, the patient was taken emergently for exploratory laparotomy under general anesthesia. At laparotomy, an enormously distended sigmoid loop with gangrenous changes was found. The sigmoid colon was resected and Hartman′s colostomy was performed. Four hours postoperatively a dead male foetus was delivered following Syntocinon augmentation. The patient had an uneventful postoperative course thereafter and was discharged on a regular diet on postoperative day 10 after stitch removal.DISCUSSION Sigmoid volvulus should always be considered in a pregnant woman with intestinal obstruction. [6] , [7] It is therefore especially important to be aware of this condition, which has a significant maternal and foetal mortality rate. [8] Usually, nonspecific clinical diagnosis of intestinal obstruction is made and experience of this condition enabled the specific diagnosis in this case.The pathogenesis may possibly be ascribed to an enlarging uterus pushing the long redundant sigmoid colon out of the pelvis, which then twists around its point of fixation on the pelvic sidewall. [9] Unfortunately, the pregnancy itself clouds the clinical picture because abdominal pain and leucocytosis are otherwise normal findings in pregnancy. In addition, hesitation in obtaining radiography contributes to delayed diagnosis. The aim of management is to reduce the morbidity and mortality of both the mother and the fetus; however, this is frequently a challenging task. Aggressive resuscitation followed by early surgical intervention through a standard midline incision allows maximal exposure with minimal uterine manipulation. [8] Nonviable bowel should be resected and diverting colostomy performed. [7] Viable sigmoid should be derotated and deflated by sigmoidoscopic placement of rectal tube, and resection postponed to some point in the postpartum period. Conservative decompression via rectum is often unsuccessful as the large gravid uterus acts as a mechanical impediment to detorsion. [6] Sigmoid volvulus complicating pregnancy has potentially devastating developments. As such, a high index of suspicion together with prompt intervention minimizes maternal and foetal morbidity and mortality. REFERENCES
Copyright 2005 - Indian Journal of Medical Sciences The following images related to this document are available:Photo images[ms05048t1.jpg] |
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