DIAGNOSTIC DILEMMA OF SIGMOID VOLVULUS COMPLICATING PREGNANCY

Abstraction

We report the instance of a 34 year-old Malay, admitted for irregularity and abdominal hurting at 35 hebdomads of gestation. Initially, she was diagnosed to hold paralytic intestinal obstruction and was managed cautiously. As her status did non better, exigency laparotomy was performed for suspected enteric obstructor. She delivered a babe male child weighing 2.84kg with good Apgar mark through a cesarean subdivision. Intra-operatively, she was noted to hold sigmoid volvulus and sigmoidopexy was performed. Post-partum, colonoscopy and intestine decompression was performed. She recovered good and was discharged on twenty-four hours 5.

This instance illustrates the demand to name or surmise volvulus in pregnant adult female showing with terrible irregularity as early surgical intercession can cut down morbidity to both female parent and foetus.

( Cardinal words: diagnosing, sigmoid, volvulus, gestation, complication )

Introduction

Volvulus of intestine during gestation and puerperium frequently posed diagnostic challenge to handling clinicians due to several factors. It has been reported that the prevalence is merely 1 in 66,451 gestations 1-3. These occur commonest in the sigmoid colon, with 44 % of instances 4. Due to its rareness, this status is frequently non considered as differential diagnosing. Furthermore, the predominant symptoms of volvulus are irregularity and abdominal cramp-like hurting doing it hard to separate this status from other gestation related status or surgical exigencies such as appendicitis and peptic ulcer.

Delay in intervention may ensue in infected daze or even decease in female parent and foetus. It has been reported that maternal and foetal mortality was 13 and 20 per centum severally 3.

Case Report

A 34-year- old gravida I lady was admitted at 35 hebdomads of gestation after a 10-day history of abdominal hurting, sickness and emesis. Associated with these, was irregularity. On admittance, she was dehydrated but afebrile with blood force per unit area 120/70mmHg. Clinical scrutiny revealed tender venters without rigidness or contractions. The intestine sound was sulky. The womb corresponded to 36 hebdomads of gestation and the os was closed.

Urinalysis showed no mark of urinary piece of land infection. Her entire white cells, urea, serum electrolytes and amylase were normal. Cardiotocography was reactive with no contractions documented. Ultrasonography revealed a foetus with parametric quantities matching to 36 hebdomads and there was no obvious breaking off placenta seen.

She was treated cautiously for paralytic intestinal obstruction and kept nothings by oral cavity with nasogastric tubing aspiration plus endovenous unstable re-hydration. An exigency laparomotmy was undertaken as her status did non better. A healthy babe boy weighing 2.84kg with good Apgar mark and pH of 7.321 was delivered through a lower section cesarean subdivision. A sigmoid volvulus ( Figure 1 ) was found and sigmoidopexy was performed. Post-laparotomy, intestine decompression was performed via colonoscopy. She had an uneventful recovery and was discharge good on twenty-four hours 5.

Discussion

Volvulus is the 2nd most common cause of enteric obstructor after adhesion in gestation 3. Pregnancy itself is said to be the precipitating factor for happening of volvulus. It is postulated that the big womb can do a redundant or abnormally elongated sigmoid colon to lift out of its pelvic girdle and turn around its arrested development point on the pelvic side wall 5.

Excessively frequently, the diagnosing of volvulus is non being considered as diagnosing due to its rareness and besides its non-specific symptoms which may mime gestation related conditions or even surgical exigencies.

This patient was 35 hebdomads of gestation at the clip of diagnosing. The incidence of volvulus has been shown to increase with increasing gestation particularly during rapid expansion of the uterine size ( between 16-20 and 32-36 ) 6. During those periods, the hypertrophied womb will compact on the distal colon and interrupt the normal colorectal map and terminal act of laxation automatically and reflexly. Stasis of the gall during gestation will further cut down the motility of the bowel. During ulterior phase of gestation, foetal caput battle will ensue in addition force per unit area of the rectum and doing laxation an anopelvicrectal attempt.

The diagnosing of enteric obstructor during gestation is based on the same three of symptoms found in the general population aa‚¬ ” abdominal hurting, purging and irregularity. Retrospectively, this patient presented with all the classical symptoms of enteric obstructor. Nevertheless, conservative attack was taken as the diagnosing of enteric obstructor was non converting in position of its rareness. Furthermore, she had no hazard factor for such status eg no old surgery. Constipation is a common symptom among adult females taking hematinics and crampy abdominal hurting could resemble either labor hurting or even urinary piece of land infection. It was merely after her symptoms did non improved and we had ruled out gestation related problem- urinary piece of land infection, breaking off placenta, she was subjected to exigency laparotomy for suspected enteric obstructor.

Prior to surgery, we did non surmise her to hold a volvulus therefore no apparent abdominal X ray was requested. Although many seldom performed apparent abdominal X ray in fright of overexposing foetus to radiation, it was reported that it may be diagnostic in 80 % of instances. The classical findings on the movie would be a dead set inner tyre mark with its vertex pointing towards the left lower quadrant 7.

During the abdominal geographic expedition, sigmoid volvulus was revealed and sigmoidopexy was performed as the bowels were still feasible. Sigmoidopexy nevertheless, does non forestall return and therefore colonoscopy was performed post-operatively to uncompress the intestine. In a instance of non-viable intestine, sigmoid colectomy and Hartmannaa‚¬a„?s process would be the option.

On the other manus, if volvulus was suspected much earlier, colonoscopy should hold been offered as it has a high decrease rate ( 60-90 % ) 8,9. There had been several studies on the success colonoscopic detorsion and rectal tubing decompression particularly during early gestation without peritonism. It is safe to reiterate this method until the foetus had reached adulthood 10. Due to high return rate of more than 50 % during gestation, these adult females would finally necessitate surgical intercession.

In decision, acute enteric obstructor due to sigmoid volvulus in pregnant adult females poses direction challenge to the attention accoucheurs and sawboness. Radiological and colonoscopic scrutiny may hold a function in naming the status and therefore assist to cut down the morbidity and mortality to both female parent and foetus.