Abstract
Volvulus in pregnancy is rare and difficult to diagnose. Delayed diagnosis would result in high maternal and fetal mortality. Here we present an unusual case of small bowel volvulus in late pregnancy timely managed by emergency Cesarean section and derotation with excellent maternal and fetal outcomes. Volvulus should be considered in patients complaining ongoing abdominal pain, nausea, vomiting, constipation even diarrhea. Imaging is essential for early and precise diagnosis, including plain abdominal film, MRI and/or ultrasound. Once highly suspected or diagnosed of volvulus or ileus, emergency laparotomy should be performed immediately to avoid catastrophic outcomes, because the maternal and fetal prognosis is dependent on the interval from volvulus to operation apart from the degree of volvulus.
Keywords: Small bowel volvulus, pregnancy, early diagnosis
Introduction
The incidence of volvulus in pregnancy has been described as 1/1,500-66,000 deliveries [1]. Abdominal pain, nausea and vomiting are most common symptoms of volvulus, which happen to be common complaints in pregnancy. Uterine enlargement gradually displaces the bowel and make the signs of volvulus untypical. Thus, volvulus in pregnancy is rare and difficult to diagnose. Delayed diagnosis would result in high maternal and fetal mortality. Here we present an unusual case of small bowel volvulus in late pregnancy timely managed by emergency Cesarean section and derotation with excellent maternal and fetal outcomes.
Case report
A 26-year-old, Gravida 1, Para 0, woman at 37 weeks plus 2 days of gestation was admitted to our emergency room, with a history of continuous abdominal pain in epigastrium while sitting in the chair 2 hours ago. Nausea, vomiting and soreness of the loins and normal defecation were reported. On admission, physical examination revealed normal bowel sounds, weakly positive percussion pain in renal region, occasionally tangible uterine contraction, negative abdominal tenderness or rebound tenderness. History included appendectomy 14 years ago and no systemic diseases existed. Abdominal ultrasound revealed normal images in uterus, fetus, placenta, liver, gallbladder, pancreas, spleen, kidney, ureter and no free fluids in abdominal cavity. Electronic fetal monitoring was normal. Laboratory examination (Table 1) revealed WBC 10.2 × 109/L, Neutrophil 77%, elevated procalcitonin (PCT) 0.39 ng/mL (0-0.25 ng/mL) and normal C-reactive protein (CRP), urine protein 1+, hepatic, renal, coagulation function, blood and urine amylase, and blood glucose, lipid levels. Rechecked urine routine by urethral catheterization showed negative urine protein. Fasting, fluid replacement, antibiotics and antispasmodics were given. Upper abdominal pain temporarily slightly relieved but consistently existed. Three hours later, laboratory examination showed WBC 13.64 × 109/L, Neutrophil 93%, elevated procalcitonin (PCT) 0.28 ng/mL (0-0.25 ng/mL) and normal C-reactive protein (CRP), urine protein. Six hours later, WBC increased to 14.33 × 109/L, Neutrophils up to 94%. In condition of persistent abdominal pain and invalid conservative treatment, we determined to perform emergency exploratory laparotomy to identify the diagnosis for maternal and fetal safety. Although not obstetrically indicated, Cesarean section at term was first performed through a midline incision for convenience of the following exploratory laparotomy. Upon entering the abdominal cavity, a small quantity of chyliform peritoneal fluid was noticed. Peritoneal fluid cultures were obtained. Cesarean section was unremarkable and a healthy female baby was delivered with a weight of 3180 g and Apgar score 9’ and 9’ in 1st and 5th minute. Greater omentum adherent to right pelvic wall and volvulus of small intestine around the mesentery were observed. The small intestine showed slightly ischemic changes and no necrosis or perforation was seen. Adhesiolysis and de-rotation of small intestine were performed and small intestine restored blood supply in 1 minute (Figure 1). Postoperative plain abdominal radiograph was normal and placenta pathology revealed chorioamnionitis. The patient was discharged uneventfully on the 7th postoperative day.
Table 1.
Laboratory examinations results were listed as follows
| Admission Time | Blood routine | Urine routine | PCT (ng/mL) | CRP (mg/L) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
| ||||||||||
| WBC (× 109/L) | N (%) | L (%) | Hb (g/L) | PLT (× 109/L) | Protein | WBC | RBC | |||
| 0 h | 10.2 | 77 | 19 | 130 | 97 | 1+ | (-) | (-) | 0.39 | / |
| 3 h | 13.64 | 93 | 5 | 117 | 90 | (-) | 0-1 | 0-1 | 0.28 | < 10 |
| 6 h | 14.33 | 94 | 5 | 120 | 93 | / | / | / | / | / |
| 24 h/P1 | 17.04 | 88 | 6 | 109 | 86 | (-) | (-) | 8-10 | 0.15 | / |
| 96 h/P4 | 12.12 | 82 | 12 | 114 | 157 | / | / | / | / | 33 |
P: postoperative day, WBC: white blood cells count, N: neutrophils, L: lymphocytes, Hb: hemoglobulin, PLT: platelets count, PCT: procalcitonin, CRP: C-reactive protein, /: not examined.
Figure 1.
Adhesiolysis and de-rotation of small intestine were performed and small intestine restored blood supply in 1 minute. No necrosis or perforation was seen.
Discussion
The incidence of volvulus in pregnancy has been described as 1/1,500-66,000 deliveries [1]. Volvulus accounts for 25% of small bowel obstructions in pregnant women, but only 3-5% in nonpregnant women [2]. Other causes of gestational intestinal obstruction include adhesions, intussusceptions, hernia and cancer [3,4].
Volvulus in mid and late pregnancy can happen in most sites of gastrointestinal tract, including stomach [5], duodenum [6], small bowel [7], cecum [8], ascending colon [3], transverse colon [9], sigmoid [10]. Among them, sigmoid volvulus is the most frequent cause of intestinal obstruction during pregnancy accounting for 25% to 44% of published cases [1,11,12]. Since midgut comprises the portion from the distal half of 2nd part of duodenum to the proximal 2/3 of transverse colon, volvulus in these sites is also called midgut volvulus. The mortality rate of midgut volvulus in pregnancy is significantly higher (3-15%) with respect to the general population [3,13,14]. It is a surgical emergency and if not diagnosed early carries a high mortality rate for both mother (6-20%) and fetus (20-26%) [1,15]. Small bowel volvulus is rare and part of midgut volvulus. The most common predisposing factors of volvulus include presence of congenital malrotation as well as adhesions from previous operations [7] and our case belongs to the latter.
We search “((volvulus pregnancy) OR volvulus pregnant) AND English” without other restriction in PubMed and acquired 299 articles. Apart from our case, there are 22 reports about small bowel volvulus in mid and late pregnancy during the past 20 years. Clinical characteristics are summarized in Table 2.
Table 2.
Clinical characteristics of volvulus in pregnancy of cases in the past 20 years
| Clinical characteristics | No./Sum | Proportion |
|---|---|---|
| Predisposing factor | ||
| Abdominal operation | 15/28 | 53% |
| Intestinal operation | 5/15 | 33% |
| Laparoscopic Roux-en-Y gastric bypass | 3/15 | 20% |
| Long-term gastrointestinal discomfort | 3/28 | 11% |
| Unremarkable history | 10/28 | 36% |
| Gestational stages | ||
| 2nd trimester | 10/29 | 34% |
| 3rd trimester | 19/29 | 66% |
| Symptoms | ||
| Abdominal pain | 21/23 | 91% |
| Vomiting | 19/23 | 83% |
| Nausea | 10/23 | 48% |
| Constipation | 5/23 | 22% |
| Diarrhea | 2/23 | 9% |
| Signs | ||
| Abdominal tenderness | 10/23 | 43% |
| Hypoactive bowel sounds | 6/23 | 26% |
| No bowel sounds | 2/23 | 9% |
| Normal bowel sounds | 3/23 | 13% |
| Lab tests | ||
| Blood WBC counts | ||
| Progressively elevated or > 15 × 109/L | 9/16 | 56% |
| < 15 × 109/L | 7/16 | 44% |
| CRP | ||
| Elevated | 2/5 | 40% |
| Normal (< 10 mg/L) | 3/5 | 60% |
| Elevated PCT (> 0.25 ng/mL) | 1/1 | 100% |
| Imaging | ||
| Ultrasound | ||
| Dilated bowel loops | 4/9 | 44% |
| Intraperitoneal or pelvic free fluid | 4/9 | 44% |
| No abnormal lesion | 1/9 | 12% |
| Conclusive plain abdominal film | 5/5 | 100% |
| Conclusive CT | 6/6 | 100% |
| Conclusive MRI | 2/2 | 100% |
| Operations | ||
| Resection of bowel | 19/28 | 68% |
| Multiple operations | 2/28 | 7% |
| Re-look laparotomy | 2/28 | 7% |
| Derotation | 4/28 | 14% |
| Reducing internal hernia | 2/28 | 7% |
| Ladd’s band incision | 1/28 | 4% |
| Laparotomy | 1/28 | 4% |
| Endoscopy | 1/28 | 4% |
| Fetal outcomes | ||
| Good | 21/27 | 78% |
| mild asphyxia | 2/27 | 7% |
| severe asphyxia | 2/27 | 7% |
| Dead | 6/27 | 22% |
| Maternal outcomes | ||
| Uneventful | 20/28 | 72% |
| Short bowel syndrome | 6/28 | 21% |
| Expired | 2/28 | 7% |
Abdominal operation history and long-term gastrointestinal discomfort are the main predisposing factors, with the incidence of 53% (15/28) and 11% (3/28), respectively. In addition, 33% (5/15) of abdominal operations belong to intestinal operation. However, 36% (10/28) have unremarkable history. In accordance with the increasing impact of enlarged uterus on the anatomy of gastrointestinal tract, 66% (19/29) of volvulus occur in the 3rd trimester, while 34% (10/29) in the 2nd trimester.
The most frequent symptoms include abdominal pain, vomiting and nausea with the incidence of 91% (21/23), 83% (19/23), and 48% (11/23), respectively. Constipation and diarrhea are uncommon with the incidence of 22% (5/23) and 9% (2/23). Different from the intermittent, paroxysmal, regular pain of uterine contraction, abdominal pain of volvulus is ongoing and mostly epigastric. Due to impact of the pregnancy uterus, the incidence of positive signs is much lower with abdominal tenderness 43% (10/23), hypoactive bowel sounds 26% (6/23), no bowel sounds 9% (2/23). Notably, normal bowel sounds exist in 13% (3/23) of cases. That is, normal bowel sounds simply fail to exclude volvulus. With respect to laboratory tests, 50% (8/16) of blood WBC counts are progressively elevated over time or > 15 × 109/L, and 50% (8/16) are tested one time and normal. The rapidly, progressively elevated inclination of blood WBC counts within 1 day implies the necessity of following up blood routine every several hours. C-reactive protein (CRP) are elevated in 40% (2/5) and normal in the rest. The 116-aminoacid polypeptide procalcitonin (PCT), a precursor to a hormone involved in calcium metabolism, is described as “the champion so far” when it comes to identifying bacterial infections [16]. In addition, PCT is a helpful biomarker for early diagnosis of sepsis in critically ill patients [17]. In our case, PCT shows earlier elevation than blood WBC and decreases but remains abnormally rising after antibiotics injection. However, blood WBC gradually rises despite antibiotics therapy. Thus, combination examination of blood WBC counts, CRP and PCT periodically may help early detection of bacteremia and septicemia.
Imaging is essential for early and precise diagnosis. One hundred percent of plain abdominal film (5/5), CT (6/6) and MRI (2/2) provide conclusive evidence of volvulus or occlusion. In addition, ultrasound reveal dilated bowel loops occur in 44% (4/9), intraperitoneal or pelvic free fluid in 44% (4/9), no abnormal lesion in 12% (1/9). The mean dose of abdominal plain film is 1.4 mGy and the maximum dose is 4.2 mGy; the mean dose of abdominal CT is 8 mGy and the maximum dose is 49 mGy [18]. There is no evidence in either humans or animals that radiation exposure in the diagnostic ranges (i.e. < 50 mGy) is associated with an increased incidence of any significant congenital malformation [19]. Thus, both abdominal plain film and CT are safe for fetus, with the former much safer. Furthermore, MRI may offer significant advantages in such cases without the risk of ionizing radiation [20]. MR imaging may be used in pregnant women if other nonionizing forms of diagnostic imaging are inadequate or if the examination provides important information that would otherwise require exposure to ionizing radiation (e.g., fluoroscopy, computed tomography). Pregnant patients should be informed that, to date, there has been no indication that the use of clinical MR imaging during pregnancy has produced deleterious effects [21]. In sum, plain abdominal film, MRI and/or ultrasound belong to the first choice, while CT can be chosen if necessary.
The rate of bowel resection is high to 68% (19/28) and the rate of derotation, reducing internal hernia, Ladd’s band incision is 14% (4/28), 7% (2/28), 4% (1/28), respectively. In one (1/28) laparotomy, surgical intervention was deferred and the abdomen was closed again because of the extensive bowel infarction and the patient expired due to septicemic shock within a few hours [3]. Notably, upper gastrointestinal endoscopy is applied in 1 case to diagnose and manage of placing a naso-jejunal feeding tube beyond the obstruction from 20w till spontaneous delivery at 34 w. As regards to fetal prognosis, fetal mortality is 22% (6/27) while both the rate of mild asphyxia and severe asphyxia are uniformly 7% (2/27). For maternal outcome, maternal mortality is 7% (2/28) and 21% (6/28) suffer from short bowel syndrome with catastrophic complications caused by massive small bowel resection.
Notably, postoperative placenta pathology revealed chorioamnionitis though a well-appearing newborn was delivered with Apgar score 9’ and 9’ in 1st and 5th minute. Histologic chorioamnionitis (HCA) is associated with preterm delivery, neonatal morbidity and mortality [22] and increased risk for early onset clinical sepsis among term infants admitted to the NICU for suspected sepsis [23]. Because HCA is usually subclinical, histologic examination of the placenta is essential for confirmatory diagnosis [23]. In our case, HCA reveals the potential early onset sepsis in mother and fetus and demonstrates the necessity of timely exploratory laparotomy.
In conclusion, volvulus should be considered in patients complaining ongoing abdominal pain, nausea, vomiting, constipation even diarrhea. Blood routine, CRP and PCT can be repeatedly examined in one day. Imaging is essential for early and precise diagnosis, including plain abdominal film, MRI and/or ultrasound. Once highly suspected or diagnosed of volvulus or ileus, emergency laparotomy should be performed immediately to avoid catastrophic outcomes, because the maternal and fetal prognosis is dependent on the interval from volvulus to operation apart from the degree of volvulus.
Disclosure of conflict of interest
None.
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