Bowel obstruction is a rare and difficult diagnosis in pregnancy1.
An infrequent case of combined small and large bowel obstruction which presented diagnostic difficulty is reported.
40 yrs old primigravida presented at term, with nonspecific abdominal pain and decreased fetal movements for 24 hours. She had an uneventful antenatal period with a known small anterior uterine wall fibroid. Initial investigations confirmed foetal wellbeing with no identifiable obstetric or non-obstetric cause for pain. After initial conservative management, she was induced and went on to have a normal vaginal delivery.
On day 3 postpartum, she developed acute generalised abdominal pain. The pain was severe in intensity and associated with mild but progressive abdominal distension. Investigations were initiated, and her care transferred to the HDU on delivery suite. Her blood results were normal and the ultrasound scan showed moderate abdominal ascites, with the AXR showing prominant loops of bowel (Fig.1).
The initial multidisciplinary review by the surgeons attributed the pain to be due to constipation or pseudoobstruction. Six hours later, the patient became mildly pyrexic with tachycardia of 130 bpm and ST changes on her ECG. Cardiac investigations excluded cardiomyopathy. The patient developed bilious vomiting, prompting an urgent surgical re- review and transfer of care. She was then managed as a case of acute bowel obstruction and underwent abdominal CT scan (Fig.2) followed by laparotomy. She had a double volvulus of sigmoid colon and distal ileum. Both loops of bowel were infarcted but not perforated. She underwent segmental small bowel resection with primary anastomosis and sigmoid colectomy with end colostomy and closure of rectal stump.
A high index of suspicion is necessary for the diagnosis of bowel obstruction due to volvulus after obstetric delivery.
1. ConnollyMM, Un, JA, Nora PF. Bowel obstruc,on in pregnancy. Surg Clin North Am1995 Feb; 75(1):101-‐13.