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\begin{document}

\title{Sigmoid volvulus as a cause of Intestinal obstruction in pregnancy: A
case report}



\author[1]{Paul Naseef}%
\author[1]{Ayman Abou Elnour}%
\author[1]{Ahmed Ramy}%
\affil[1]{Ain Shams University Faculty of Medicine}%


\vspace{-1em}



  
  \date{June 17, 2024}


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\selectlanguage{english}
\begin{abstract}
Sigmoid volvulus is one of the rare causes of intestinal obstruction in
pregnancy and can result in significantly increased maternal and fetal
mortality rates, especially in case of delayed diagnosis. In this
report, we present a 34 week-pregnant lady presenting with intestinal
obstruction due to sigmoid volvulus and her management.%
\end{abstract}%



\sloppy


\textbf{Sigmoid volvulus as a cause of Intestinal obstruction in
pregnancy: A case report}

Paul Naseef, Ayman Abou Elnour, Ahmed Ramy

Obstetrics and Gynecology Department, Ain Shams University, Cairo, Egypt

\textbf{Correspondence}

Paul Naseef, ORCID: 0000-0003-4279-5844

Obstetrics and Gynecology Department, Ain Shams University, Cairo, Egypt

Email: paulabeh@hotmail.com

\textbf{Funding information}

None

\textbf{ABSTRACT}

Sigmoid volvulus is one of the rare causes of intestinal obstruction in
pregnancy and can result in significantly increased maternal and fetal
mortality rates, especially in case of delayed diagnosis. In this
report, we present a 34 week-pregnant lady presenting with intestinal
obstruction due to sigmoid volvulus and her management.

\textbf{KEYWORDS}

Sigmoid volvulus, intestinal obstruction, colostomy

\textbf{INTRODUCTION}

Intestinal obstruction (IO) in pregnancy, first reported by Houston in
1830, is a rare but extremely serious condition that has a high maternal
and fetal mortality rate owing to delayed diagnosis. The reported
incidence of intestinal obstruction complicating pregnancy ranges from
one in every 66,431 to one in 1,500 births. A retrospective study of 66
cases of intestinal obstruction complicating pregnancy and the
puerperium, found that adhesive IO (58 \%), volvulus (24 \%), and
intussusception (5\%) were the most common causes of mechanical bowel
obstruction. 77\% of patients with adhesive intestinal obstruction gave
history of previous abdominal or pelvic
surgery\textsuperscript{\textbf{1}} .

In a descending order of frequency, volvulus of the colon can occur in
the sigmoid colon, caecum, splenic flexure, and transverse colon.
Sigmoid volvulus has a diverse geographical and racial distribution, and
while it is extremely common in developing countries such as African
nations, where it mainly affects young male patients, it is much less
common in the West, where it affects the elderly and frail female
patients. The Western type of sigmoid volvulus is attributed to
persistent constipation; however, a high-fiber diet has been identified
as a key factor in the development of sigmoid volvulus in African
people\textsuperscript{\textbf{2}} .

Although sigmoid volvulus~(SV) is rare, it is one of the most common
causes of bowel obstruction that occurs in pregnancy, making up to 24\%
of reported cases.~The prompt diagnosis and timely management of this
condition is challenging because its clinical picture is usually masked
by the physiological changes of pregnancy which adds to the morbidity
and mortality rates associated with this condition. Therefore, early
diagnosis and timely surgical intervention are mandatory to improving
the overall outcome\textsuperscript{\textbf{3}} .

In this case report, we present the case of a 34 week-pregnant lady
presenting with acute abdominal pain and features of bowel obstruction
due to sigmoid volvulus, and her initial, surgical and postoperative
management.

\textbf{CASE REPORT}

A 24-year-old Egyptian pregnant lady, gravida 1 and para 0, presented to
our hospital with 2 days history of intermittent lower abdominal pain
that has been exacerbated over the few hours prior to her presentation,
severe abdominal distension, and absolute constipation. She had
non-contributory past medical or surgical history with no previous
abdominal or pelvic surgeries. Her pregnancy had been uneventful until
that presentation. She reported taking up to 4 grams/day of
Acetaminophen at home with minimal pain relief.

On examination, she was extremely agitated and uncomfortable, her pulse
was 138 beats / minute, her blood pressure was 85/55 mmHg, her
respiratory rate was 32 breaths / minute and her temperature was 38.2 C.
Her abdominal examination revealed marked left lower quadrant
tenderness, rebound tenderness and rigidity.

Her laboratory investigations revealed leukocytosis with left shift
(23.2x10\^{}9/L), serum creatinine and BUN were 1.9 mg/dl and 42 mg/dl
respectively. Her serum lactate was 5.1 mg/dl. Bedside ultrasound
revealed turbid fluid reaching the hepato-renal angle. Aspiration of
this fluid, with aseptic technique, under ultrasound guidance yielded a
seropurulent discharge. Decision was taken for exploratory laparotomy
hand in hand with IV fluid resuscitation and antibiotics (2 gm of
Ceftriaxone and 500 mg of Metronidazole). The patient's mean arterial
pressure (MAP) was still 60 mmHg despite adequate fluid replacement, so
a loading dose of IV norepinephrine infusion was started at a rate of 10
mcg/min followed by a maintenance dose of 6 mcg/min to optimize
patient's blood pressure (BP).

General surgery team was called for intra-operative attendance and
patient was transferred to the operating room. A midline abdominal
incision with supra-umbilical extension was performed. Upon entry into
the peritoneal cavity, about 300 ml of seropurulent exudates were found
and suctioned. The sigmoid and transverse colon was markedly dilated and
a picture of sigmoid volvulus was found. The dilated segment of the
colon proximal to the site of obstruction friable, and gangrenous as
shown in figures 1\&2.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure (1\&2):} showing dilated gangrenous colon proximal to
site of obstruction

A lower segment caesarean section was done yielding a live female infant
weighing 1950 grams whose APGAR scores were 8 at 1 minute and 9 at 5
minutes. Mobilization and resection of the dilated gangrenous segment of
the colon was performed by the general surgery team and diverting
colostomy with a Hartman's procedure was done. 2 wide bore
intra-peritoneal were placed and mass closure of the anterior abdominal
wall was done. Delayed primary closure of the skin was undertaken 48
hours later after showing no signs of surgical site infection.

Post-operatively, the patient was kept on broad on broad-spectrum
antibiotics and was transferred to the intensive care unit (ICU) for
postoperative care. She was gradually weaned off cardiovascular support
and had a smooth postoperative course. She was discharged home 10 days
later.

\textbf{DISCUSSION}

Intestinal obstruction has a low incidence in pregnancy ranging from 1
in 1500 to 1 in 66431 deliveries. Its causes during pregnancy include
congenital or surgical adhesions, volvulus, intussusceptions, hernia,
and appendicitis. Sigmoid volvulus is one of the most prevalent causes
accounting for up to 24\% of cases\textsuperscript{\textbf{4}} .

Pregnancy itself is thought to be the trigger for sigmoid volvulus where
the gravid uterus may cause it by displacing, compressing, and partially
obstructing a redundant or abnormally long sigmoid colon. This could
explain why sigmoid volvulus occurs more frequently in the third
trimester of pregnancy as shown in our case who presented at 34 weeks
gestation. Despite the higher risk in the third trimester, reports of
this problem occurring in the first trimester as well as the puerperium
have been reported\textsuperscript{\textbf{5}} .

When a pregnant woman experiences a clinical triad of abdominal pain,
distension, and absolute constipation, the diagnosis of sigmoid volvulus
should be considered. It has been observed in literature, in match with
our case, that the mean time from the onset of obstruction to clinical
presentation is 48 hours. This is mainly due to the fact that pregnancy
can conceal the clinical picture by causing abdominal pain, nausea, and
leukocytosis in otherwise healthy women\textsuperscript{\textbf{6}} .

This delay in diagnosis and surgical intervention in pregnancy has a
substantial impact on the maternal and fetal final outcomes. These
outcomes have been directly related to the degree of bowel ischemia and
subsequent sepsis. Literature has shown that all maternal deaths occured
in patients who had a two-day or more delay in presentation and surgical
intervention. Individuals who presented after 48 hours of onset of
symptoms had 5 fetal deaths, compared to 2 fetal deaths in patients who
presented early in the disease's course. This finding emphasises the
importance of a high degree of clinical suspicion in cases of intestinal
obstruction in pregnant women. This information should be stressed to
general practitioners and community obstetricians who are largely
responsible for the treatment of these
individuals\textsuperscript{\textbf{7}} .

Intestinal obstruction in pregnant women is treated in the same way as
in non-pregnant women. Early surgical intervention is the cornerstone of
treatment preferably via a midline vertical laparotomy. If adequate
intestinal exposure cannot be acquired due to a larger gravid uterus in
the third trimester, a caesarean section must be performed. The whole
bowel should be meticulously explored for other sites of obstruction.
Intestinal viability must be carefully checked and segmental resection
with or without anastomosis is frequently
required\textsuperscript{\textbf{8}} .

\textbf{CONCLUSION}

Sigmoid volvulus complicating pregnancy is extremely rare, however, when
it occurs, may lead to considerable maternal and fetal morbidity and
mortality. In patients who present with abdominal pain, distension, and
absolute constipation, a high index of clinical suspicion is required
for prompt diagnosis. Delayed diagnosis and treatment results in higher
fetal and maternal morbidity and mortality especially after 48 hours.
Therefore, early diagnosis and appropriate surgical intervention is
crucial to improving maternal and fetal outcomes as shown in our case.

\textbf{AUTHOR CONTRIBUTION}

P. Naseef was involved in data collection, interpretation and drafting
the article. A. Abou Elnour and A. Ramy revised and edited the
manuscript. The final version to be published was approved by all the
authors.

\textbf{ACKNOWLEDGEMENTS}

None.

\textbf{CONFLICT OF INTEREST}

The authors declare no conflict of interest.

\textbf{ETHICAL APPROVAL}

This case report was approved by the Research Ethics Committee (REC) of
Faculty of Medicine, Ain Shams University.

\textbf{CONSENT}

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy.

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
  Perdue, P. W., Johnson Jr, H. W., \& Stafford, P. W. (1992).
  Intestinal obstruction complicating pregnancy.~\emph{The American
  Journal of Surgery,} ~164(4), 384-388.
\item
  Madiba, T. E., \& Thomson, S. R. (2000). The management of sigmoid
  volvulus.~\emph{Journal of the Royal College of Surgeons of
  Edinburgh,~} 45(2).
\item
  Aftab, Z., Toro, A., Abdelaal, A., Dasovky, M., Gehani, S., Abdel
  Mola, A., \& Di Carlo, I. (2014). Endoscopic reduction of a volvulus
  of the sigmoid colon in pregnancy: case report and a comprehensive
  review of the literature.~\emph{World Journal of Emergency Surgery,}
  ~9(1), 1-6.
\item
  Kolusari, A., Kurdoglu, M., Adali, E., Yildizhan, R., Sahin, H.G.,
  Kotan (2009). Sigmoid volvulus in pregnancy and puerperium: a case
  series. Cases Journal, 2:9275.
\item
  Harer, W.B. Jr., Harer W.B. Sr. (1958). Volvulus complicating
  pregnancy and puerperium; report of three cases and review of
  literature. \emph{Obstet Gynecol,} 12:399--406.
\item
  Keating J.P., Jackson D.S. (1985.) Sigmoid volvulus in late
  pregnancy.\emph{J R Army Med Corps,} 131:72--74.
\item
  Iwamoto I., Miwa K., Fujino T., Douchi T. (2007). Perforated colon
  volvulus coiling around the uterus in a pregnant woman with a history
  of severe constipation. \emph{J Obstet Gynaecol Res,} 33:731--733.
\item
  Redlich A., Rickes S., Costa S.D., Wolff S. (2007). Small bowel
  obstruction in pregnancy. \emph{Arch Gynecol Obstet,} 275:381--383.
\end{enumerate}\selectlanguage{english}
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