Saudi Journal of Gastroenterology
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Year : 1999  |  Volume : 5  |  Issue : 3  |  Page : 134-139
Small intestinal obstruction in pregnancy and puerperium


1 Department of Surgery, College of Medicine, University of Benn, Benin City, Nigeria
2 Department of Obstetrics & Gynecology, College of Medicine, University of Benn, Benin City, Nigeria

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Date of Submission31-Mar-1998
Date of Acceptance13-Apr-1999
 

   Abstract 

The problem of intestinal obstruction in pregnancy and puerperium is worsened by the risk it poses not just to the mother, but also to the fetus. In this review of 10 pregnant/puerperium patients the maternal mortality was 10% and fetal wastage 20%. In pregnancy and puerperium, intestinal obstruction carries a higher mortality, 10-33%, than in non-pregnant patients, 6-10%. The rarity of the problem, delay in diagnosis, anxiety over radiological examination in pregnant women, worry over laparotomy in pregnant women, all result in delay in instituting definite treatment and contribute to the morbidity. Application of established principles in the management of intestinal obstruction even when it occurs in pregnancy and puerperium might help to improve the results of management and reduce the current level of morbidity and mortality.

How to cite this article:
Chiedozi LC, Ajabor LN, Iweze FI. Small intestinal obstruction in pregnancy and puerperium. Saudi J Gastroenterol 1999;5:134-9

How to cite this URL:
Chiedozi LC, Ajabor LN, Iweze FI. Small intestinal obstruction in pregnancy and puerperium. Saudi J Gastroenterol [serial online] 1999 [cited 2017 May 23];5:134-9. Available from: http://www.saudijgastro.com/text.asp?1999/5/3/134/33534


The clinical presentation of small bowel obstruction abdominal pain, nausea, vomiting and obstipation are well known to all clinicians. However, when these same symptoms occur in the pregnant patient, the diagnosis of intestinal obstruction is not so readily forthcoming. The resulting delay in diagnosis exposes both the patient and her fetus to all the dire consequences of "late intestinal obstruction syndrome" [1] . Intestinal obstruction in pregnancy is rare and has hardly been mentioned in the African and Middle East medical literature. The rarity of this problem, means that clinicians must keep its possibility in mind when confronted with the suggestive symptoms of this problem in which time and early diagnosis are of such vital importance.


   Report of Cases Top


Case 1

This 23 year old woman presented with one week history of worsening cramps and intermittent epigastric pain, nausea and vomiting in the 28th week of her pregnancy. She had appendectomy two years previously and was in good health prior to the pregnancy. Nausea had been present from the early weeks of the pregnancy. Diagnosis of duodenal ulcer was made and she was commenced on intravenous fluids and natacids. She felt better but immediately developed abdominal distension and bloating when she was commenced on oral fluids 24 hours later. She was transferred to the University of Benin Teaching hospital (UBTH). Additional history revealed 48 hours of obstipation. Her abdomen was distended and mildly tender. Bowel sound was tingling. The uterine size was normal for gestation age. The rectal ampulla was empty. With working differential diagnoses that included duodenal ulcer and small intestinal obstruction, patient was started on nasogastric suction and intravenous fluids. Her electrolytes, amylase, urea and complete blood count were unremarkable. Abdominal x-ray showed multiple air-fluid levels compatible with small intestinal obstruction. At laparotomy, the small intestine was volvulated around an adhesive band from the old appendiceal stump to a point near the duodeno-jejunal junction. The band was divided and detortion of the intestine achieved. Her postoperative course was uneventful. She delivered a normal child vaginally at term.

Case 2

A 29-year-old woman was rushed to the UBTH with a referral diagnosis of ruptured ectopic pregnancy. Patient was in the 11th week of pregnancy and had been admitted elsewhere for sudden onset of severe abdominal pain and collapse. She had persistent nausea and vomiting since the fourth week of pregnancy. She had a single bowel movement on the morning of admission. Past history included laparotomy for myomectomy and a second operation for ruptured ectopic pregnancy. She had a mildly distended but non-tender abdomen. Blood studies were normal except for AS genotype. Abdominal x-ray showed two air-fluid levels in the epigastrium not thought to be consistent with intestinal obstruction. On intravenous fluids and nasogastric suction patient felt much better and remained so for the next 24 hours. Thirty hours after admission, patient developed an abrupt onset on severe abdominal pain and vomited once. Examination showed a tender distended abdomen with absent bowel sound. At laparotomy, an ileal­ileal intussusception with intestinal gangrene was found. Three feet of small intestine was resected and an entero-enterostomy performed. In the immediate postoperative period the fetus was aborted. The rest of her postoperative course was uneventful. Pathological evaluation of the resected specimen failed to reveal a specific cause of the intussusception.

Case 3

This 30-year-old woman was admitted to the hospital in the 32nd week of pregnancy with two-day history of epigastric pain, vomiting, abdominal distension and constipation. She had appendectomy at age 19 and was healthy before the pregnancy. She had one admission to another hospital in the 16th week of pregnancy with abdominal pain and bleeding which stopped on bed rest. Examination showed a mildly distended non-tender abdomen with loud bowel sounds. There was no vaginal bleeding. Abdominal x-ray showed air-fluid levels consistent with small intestine obstruction. At laparotomy, cutting an adhesive band arising from the previous appendectomy site relieved intestinal obstruction. Her postoperative course was normal and she delivered normally at term.

Case 4

Patient was a 36-year-old woman admitted to UBTH in the 35th week of pregnancy with one week history of slowly increasing crampy abdominal pain. Twenty-four hours prior to admission, pain became worse and patient vomited once. She had caesarean section two years previously. Patient was a healthy looking woman who repeatedly retched but did not vomit. The abdomen was non-tender but softly distended; bowel sounds were loud, high pitched and with occasional rushes. Diagnosis of intestinal obstruction was confirmed on abdominal roentgenogram. Following hydration, patient underwent laparotomy for relief of small intestinal obstruction due to adhesive bands. Her postoperative course was smooth. She had spontaneous labour at term and delivered a normal child.

Case 5

Patient was a 25 year old woman referred to UBTH with seven-day history of persistent abdominal pain and vomiting in the 24th week of pregnancy. She had two admissions for lower abdominal pain over the previous four weeks. Patient stopped passing gas per rectum 48 hours prior to transfer. She had caesarean section 8 years previously but had two normal deliveries since then. Examination showed a non-tender abdomen with absent bowel sounds. Abdominal x-ray finding was consistent with small intestinal obstruction. She underwent laparotomy for relief of small bowel obstruction due to adhesive bands. Her postoperative course was normal. She delivered normally at term.

Case 6

This was a 40 year old woman who was admitted in the 40th week of pregnancy with intermittent lower abdominal pain not thought on examination to be labour pains. Because of unengaged breech presentation, induction of labour was commenced. Twelve hours later, emergency lower segment caesarean section was undertaken because of fetal distress. In the immediate postoperative period abdominal pains similar to the pre-partum type appeared.

Forty-eight hours later, patient developed severe colicky abdominal pain associated with loud bowel sounds and rushes consistent with small intestinal obstruction. Following confirmation by x-ray, rehydration and preoperative nasogastric intubation, patient moved her bowel, abdominal pain disappeared and she appeared to be on her way to recovery. But 48 hours later, (96 hours postpartum), abdominal distension, visible peristaltic waves and hyperactive bowel sounds re-appeared. At laparotomy, obstruction due herniation of the distal ileum through a rent in the mesentery was found. The hernia was reduced; the mesenteric defect was repaired. Patient had an uneventful postoperative course.

Case 7

This 32-year-old woman was referred to UBTH in the 27th week of pregnancy with 10 day history of persistent vomiting. She had a similar episode of vomiting for seven days in the 20th week of pregnancy but this had subsided spontaneously. She had not suffered from nausea or vomiting in the early months of the pregnancy. She had not responded to hydration, nasogastric suction and anti­nausea medicines in the referring hospital. She had two days of obstipation. Examination showed a dehydrated but afebrile woman. Her abdomen was softly distended and non-tender. She had mildly increased bowel sounds and occasional rushes. Her blood studies showed disordered electrolytes. Following rehydration and correction electrolytes she underwent laparotomy. An ileal-ileal intussusception with an enlarged node as the leading point was found. The history of self-limited abdominal pain in the 20th week was assumed to have been a spontaneously reduced intussusception. Accordingly the current intussusception, involving 12 inches of small intestine, was resected and an entero-enterostomy performed. Her postoperative course was uneventful and she delivered normally at term. The enlarged lymph node assumed to be the cause of intussusception showed only non-specific inflammation.

Case 8

This 23-year-old primigravida was referred to UBTH in the 30th week of pregnancy with one day history of abdominal pain and anorexia because of nausea. She gave a history of chronic constipation requiring occasional enema. She had given herself an enema to relieve a 5-day constipation prior to admission. Examination showed a non-tender but softly distended abdomen. Bowel sounds were normal. Abdominal x-ray showed a few non stepladder air-fluid levels thought to be due to the enema. She was commenced on intravenous fluids, nothing by mouth and observation. Twenty-four hours later she started vomiting. Bowel sounds remained normal but repeat abdominal x-ray showed more and persistent air fluid level. At laparotomy intestinal obstruction was due to an easily reduced ileo-cecal intussusception. Postoperative course was normal. At term she delivered normally. No specific cause of intussusception could be adduced.

Case 9

This was a 40-year-old woman admitted in the 30th week of pregnancy with two-day history of abdominal pain with exacerbation over the previous 12 hours to nausea, vomiting and obstipation. She had been constipated off and on during the entire pregnancy, a normal habit during all of her 4 previous pregnancies. She had appendectomy 10 years previously. Positive findings on examination were limited to a softly distended non-tender abdomen and loud high-pitched bowel sounds. Diagnosis of small intestinal obstruction was made clinically and patient was commenced on nasogastric suction and hydration. Four hours later patient had bowel movement, and the abdominal distension decreased. Commenced on oral fluids 48 hours later, abdominal distension and vomiting reoccurred. Abdominal x-ray showed multiple air-fluid levels. Patient underwent laparotomy with relief of obstruction due to adhesive bands. Her postoperative course was uneventful. She delivered a normal child at term.

Case 10

This 34-year-old woman was admitted to another hospital in the 22nd week of pregnancy with one week history of epigastric pain, nausea, persistent vomiting weakness and prostration. With a working diagnosis of severe dehydration, gastritis and pancreatitis, patient was started on nasogastric suction, intravenous fluids, antibiotics and analgesia. Patient showed some improvement and on the 6th day post admission was started on oral fluids. Forty-eight hours later patient became listless, complained of headache, abdominal pain, nausea without vomiting and loss of appetite. Her temperature was noted to be 38°C. She was given a dose of chloroquine injection with apparent defervescence. Twenty-four hours later patient suddenly collapsed and was rushed to UBTH. On admission patient's temperature was 40°C, pulse 136, respiration 24 and Blood Pressure 80/50. She was conscious but listless. Her chest was clear, abdomen was distended, exquisitely tender and there were no bowel sounds. There was no history or scar of previous abdominal surgery. Her blood studies showed anemia, abnormal electrolytes and acidosis. Abdominal x-ray showed air-fluid levels and gas in the walls of the some intestinal loops. Diagnoses of gangrenous intestine with gram negative septicemia, acidosis, dehydration and electrolyte imbalance were made. In addition to nasogastric suction, she was commenced on large doses of antibiotics. Shock, electrolytes imbalance and acidosis were corrected. At laparotomy, the peritoneal fluid was bloody and malodorous. Most of the intestine was found in a tight volvulus. Eight feet of gangrenous small intestine was resected. Patient and her fetus died 12 hours later.


   Discussion Top


A retrospective review of our records over the last 15 years showed that ten pregnant women were admitted to the University of Benin Teaching Hospital, Benin City, Nigeria, with proven diagnosis of small intestinal obstruction. They ranged in age from 23 to 40 years of age. Of the 10 patients, six (60%) had undergone previous abdominal operation. One of the patients presented in the first trimester of pregnancy, two in the second trimester while 7 (70%) presented in the third trimester. [Table - 1] shows details of the patients' characteristics and results of management.

The commonest cause of intestinal obstruction in pregnancy and puerperium in this hospital is adhesive bands. This finding conforms to previous report [2]. Volvulus, the second commonest cause of intestinal obstruction in this study, has been identified as the commonest cause of intestinal obstruction in pregnancy in some reports [3],[4] It is however, generally accepted that in most of the cases of volvulus, the intestine volvulate around an adhesive band and that the primary cause is adhesive bands. In a study on the general population of patients in this hospital and in reports from other African countries the commonest cause of intestinal obstruction is inguinal hernia [5],[6] . An adhesive band is the commonest cause of small intestinal obstruction in most Western countries [7],[8] Intussusception occurred in three of our patients. The leading point in adult intussusception is usually a tumor or some abnormality of the intestinal wall. This is in contrast to the pediatric intussusception where it can occur without an identifiable cause for the lead point. Intussusception among our patients seems to behave like the pediatric form of the disease. In only one of the three patients was a specific cause found. This finding has also been noted in a study of the general population of patients in this hospital [1],[6] . This hospital is located close to an area of Nigeria from where the greatest incidence of intussusception in the world has been reported [9] .

The consequences of intestinal obstruction in pregnancy do not differ from those found in non­pregnant women except that in the pregnant patient, a second entity, the fetus, is also threatened. Thus in addition to the other well documented ills of intestinal obstruction, attention must be called to the added problem of fetal wastage especially as this complication can probable be reduced substantially [1],[7],[8],[10] . In this small series, there was fetal wastage of 20%. The picture is grimmer if one looks at fetal wastage in relation to small intestinal obstruction in the earlier months of pregnancy. Thus our one patient who presented in the first half of the pregnancy lost her fetus. All seven of our patients who presented in the third trimester, the period when fortuitously most of the intestinal obstruction tend to occur, preserved their pregnancy to term and delivered normally without fetal loss.

Evidence in this hospital has shown that late presentation of the patient with small intestinal obstruction is of the direst consequence to the patient as it virtually ensures bowel gangrene [1],[6] . Two (20%) of our 10 patients who presented late lost their fetuses, required bowel resection for intestinal gangrene and one of them died. Reported maternal mortality for intestinal obstruction in pregnancy, 10-33% [2],[3],[4] , is higher than in non­pregnant patients, 6-10% [6],[7],[8] . Mortality in this study was 10%. A major problem of intestinal obstruction in pregnancy, one that impedes early institution of definitive management, is the question of diagnosis. Among our patients, the clinical presentation of intestinal obstruction in pregnancy did not differ significantly from the presentation of intestinal obstruction in our non-pregnant patients [6] . Rather, the presence of pregnancy introduced other considerations and differential diagnoses thus complicating arrival at the correct diagnosis. In the first half of the pregnancy, nausea, vomiting and episodes of constipation are quite common, as are hyperemesis gravidarum, acute duodenal ulcer and gastritis. In the second half of the pregnancy, other differentials; toxemia, constipation, Braxton-Hicks contractions, abruptio placentae make the diagnosis of small intestinal obstruction less obvious. Thus in six of our patients there was a delay of up to 72 hours before the correct diagnosis was made. Several reasons contribute to the delay in the diagnosis of intestinal obstruction in pregnancy. These include the rarity of the problem and the reluctance of clinicians to perform radiological examinations in pregnant women. Reported incidence of intestinal obstruction in pregnancy is only 1-3/10,000 pregnancies [12] . The question whether it is safe to expose the fetus to x-ray always preys on the clinician's mind. It has been shown in experimental animals that gestational exposure to x-ray below 10-20 cGy does not produce detectable increase in the incidence of congenital anomalies or microcephaly [12] . The United States National Council on Radiation Protection considers exposure of 5cGy or less to be negligible compared with other risks of pregnancy. Diagnostic abdominal x-ray in the pregnant women thus appears to be acceptable risk in the appropriate setting. Although it has been pointed out that a simple abdominal x-ray is not always reliable in the diagnosis of intestinal obstruction in pregnancy [12] , it was diagnostic in all of our cases. The net effect of delay from various causes is that specific therapy commences after the intestinal obstruction has evolved further along a route that inexorably leads to intestinal gangrene.

Early diagnosis of small intestinal obstruction in pregnancy is aided by some salient facts. First, most intestinal obstruction in pregnancy occurs in the third trimester. Secondly, while nausea and vomiting occur in 85% of pregnant women, protracted vomiting beyond mid pregnancy is rare. Management of these patients should not be hampered by reluctance to perform surgery in pregnant patients or fear of premature labor. There is now ample evidence that abdominal surgery in the third trimester does not induce labor [13],[14] Saunders and Milton advise early surgical intervention in acute abdominal conditions in pregnancy [15] . They point out that a negative laparotomy carries little risk of disturbing the pregnancy. Thus in a large series of patients who presented with non-obstetric surgical problems in pregnancy, no significant increase in perinatal mortality was found [16] It is the severity of the inflammatory response associated with the surgical disease rather than anesthesia and the surgical procedure that determine the outcome of the pregnancy [13],[14]

Clearly the consequences of late intestinal obstruction represent an infinitely worse alternative to premature labor in the third trimester. Volvulus and intussusception, two major causes of small intestinal obstruction in pregnancy, take a heavy toll of the patient in terms of morbidity and mortality [1],[8],[9] . In recent times, the risk to the third trimester premature neonate has been further reduced by the availability of tocolytic agents and recent advances in anesthesia and neonatology. All attempts must therefore be made to follow established principles in the management of intestinal obstruction when it occurs in pregnancy and puerperium. Finally, since intestinal obstruction in pregnancy is so uncommon, a high index of suspicion, rapid resort to radiological examination in the appropriate clinical setting and adherence to standard therapeutic principles will probably help to improve the results of the management of intestinal obstruction in pregnancy.

 
   References Top

1.Chiedozi LC, Bowel Gangrene. Am J Surg 1981;142:622-4.  Back to cited text no. 1    
2.Perdue PW, Johnson HW Jr, Stafford PW. Intestinal obstruction complicating pregnancy. Am J Surg 1996;164:384-7.  Back to cited text no. 2    
3.Gibney EJ, Volvulus of the sigmoid colon. Surg Gynecol Obstet 1991;173:243-8.  Back to cited text no. 3    
4.Ballantyne GH. Review of sigmoid volvulus; Clinical patterns and pathogenesis. Dis Colon Rectum 1982;25:823-5.  Back to cited text no. 4  [PUBMED]  
5.Adesola AO. Intestinal obstruction in: Schwartz SK, Adesola AO, Elebute EA, eds. New York McGraw-Hill 1971:274.  Back to cited text no. 5    
6.Chiedozi LC, Aboh IO, Piserchia NE. Mechanical bowel obstruction. Am J Surg 1980;139:389-93.  Back to cited text no. 6  [PUBMED]  
7.Ottigner LW. Small bowel obstruction in: Morris PJ, Malt RA, eds. Oxford Textbook of Surgery Oxford University Press, New York 1994:961-5.  Back to cited text no. 7    
8.Jones RS. Intestinal obstruction in: Sabiston DC, Lyerly HK, eds. Sabiston Text book of Surgery WB Saunders Philadelphia 1997:Chapter 31.  Back to cited text no. 8    
9.Cole GJ. A review of 436 cases of intestinal obstruction in Ibadan. Gut 1965;6:151-6.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Barnett WO, Morris L, In vivo effects ofperitoneal fluid resulting from strangulated intestinal obstruction. Am J Surg 1958;96:387-91.  Back to cited text no. 10    
11.Barnett WO, Oliver RI, Elliot RL. Elimination of the lethal properties of bowel gangrene. Ann Surg 1968;167:912-9.  Back to cited text no. 11    
12.Martin RH, Perry KG, Morrison J Surgical Disease and Disorders in Pregnancy in: De Chemey AH, Pemoll ML, eds. Current Obstetrics & Gynecology Diagnosis & Treatment 2nd ed. Appleton & Lange Norwalk:1994:493.  Back to cited text no. 12    
13.McKellar DP, Anderson CT, Boynton CJ, Peoples JB. Cholecystectomy during pregnancy. Surg Gynecol Obstet 1992;174:465-8.  Back to cited text no. 13  [PUBMED]  
14.Ghulmman E, Barry M, Grace PA. Management of gall stones in pregnancy. Brit J Surg 1997;84:1646-50.  Back to cited text no. 14    
15.Saunders P, Milton PJB Laparotomy during pregnancy: An assessment of diagnostic and foetal wastage. Brit Med J 19973;3:165-7.  Back to cited text no. 15    
16.Kammerer WS. Non obstetric surgery during pregnancy. Med Clin North Am 1979;63:1157-63.  Back to cited text no. 16  [PUBMED]  

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Correspondence Address:
Lawrence C Chiedozi
Prince Abdul Rahman Sudery Hospital, P.O. Box 612, Sakaka, Al Jouf, Saudi Arabia

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