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CASE REPORT
Year : 2022 | Volume
: 55
| Issue : 6 | Page : 225-228
Sigmoid volvulus in pregnancy: Case report and literature review
Tarik Souiki1, Tayeb Ouazzani1, Badreeddine Alami2, Ahmed Zerhouni1, Karim Ibn Majdoub1, Imane Toughrai1, Khalid Mazaz1
1 Department of Visceral Surgery E3, Faculty of Medicine and Pharmacy of Fez, Sidi Mohammed Ben Abdellah University; Department of Visceral Surgery (E3), University Hospital Hassan II, Fez, Morocco
2 Department of Visceral Surgery E3, Faculty of Medicine and Pharmacy of Fez, Sidi Mohammed Ben Abdellah University; Department of Radiology, University Hospital Hassan II, Fez, Morocco
Correspondence Address:
Tarik Souiki
Department of Visceral Surgery E3, University Hospital Hassan II, Fez, Morocco. Faculty of Medicine and Pharmacy of Fez, Sidi Mohammed Ben Abdellah University, BP. 1893; Km 2.200, Sidi Hrazem Road, Fez 30000
Morocco
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/fjs.fjs_102_22
Sigmoid volvulus in pregnancy is a rare but potentially serious condition. It is related to a high risk of maternal and fetal morbidity and mortality. This is mainly due to delayed diagnosis and treatment. We report the case of a 38-year-old multiparous patient, pregnant at 32 weeks of gestation, who presented to the emergency room with intestinal obstruction evolving for 2 days. At the emergency room, radiological exploration revealed a sigmoid volvulus. Endoscopic decompression was unsuccessful. A midline laparotomy was performed urgently revealing a necrotic sigmoid colon. A sigmoidal resection with a colostomy (Hartmann's procedure) was performed. In utero, fetal death occurred intraoperatively. The patient was transferred to the intensive care unit. Induction of labor was performed on the 2nd postoperative day with vaginal delivery of a stillborn. Recovery was good with the restoration of intestinal continuity 4 months later. Through this case and a review of recent literature, we discuss the diagnostic and therapeutic difficulties of this rare entity and highlight the seriousness of delay in the management of this surgical emergency.
Keywords: Intestinal obstruction, pregnancy, volvulus
Intestinal obstruction during pregnancy is a relatively rare clinical situation. Its incidence varies from one series to another, ranging from 1/1500 to 1/66431.[1] The etiologies are varied, but sigmoidal volvulus, although rare, remains the most frequently reported cause after small bowel adhesive obstruction, with an occurrence rate between 25% and 44%.[2] The main difficulty of this condition is diagnostic and therapeutic delay, leading to colonic ischemia and subsequently to stercoral peritonitis by perforation, thus resulting in seriously unfavorable maternal and fetal prognosis. This delay is due to a lack of specificity in the clinical signs, which are misleading during pregnancy, and fear of fetal irradiation risk in radiological explorations. In this case, we discuss the diagnostic and therapeutic constraints of sigmoid volvulus related to pregnancy.
Case ReportA 38-year-old multigravida, at 32-week gestation, visited the emergency room for an intestinal obstruction syndrome evolving for 2 days. She complained of generalized abdominal pain, incoercible vomiting, and inability to pass stool or flatus. The patient had no significant previous medical history. Her current pregnancy had been uncomplicated to this point. Clinical examination revealed a tachycardic and apyretic patient with a distended and tender abdomen. The fundal height was difficult to appreciate because of a diffuse abdominal meteorism. On vaginal touch, the cervix was closed. The rectal ampulla was empty on the rectal examination. Fetal cardiotocography trace on admission was normal. Abdominopelvic ultrasound showed an ongoing monofetal pregnancy with a normal uterus and placenta. The fetal presentation was in a cephalic position with normal amniotic fluid. The biological tests showed a hyperleukocytosis of 13,700/mm3, C-reactive protein of 4 mg/L, and hemoglobin level of 14 g/dL. Serum electrolytes and other biological tests were within normal ranges. Abdominal ultrasound showed extensive colonic distension. Abdominopelvic magnetic resonance imaging (MRI) was performed. Images showed distended colic loops with a transition point at the sigmoid colon and visualization of a whirl sign. These findings were consistent with a sigmoidal volvulus with intestinal obstruction [Figure 1] and [Figure 2]. After a collegial discussion between different specialists, an endoscopic detorsion was attempted but was not successful. After administering injectable corticosteroids for fetal lung maturity and tocolytic for uterine stability, a midline laparotomy was performed. Surgical exploration revealed a distended colon proximal to a volvulated and gangrenous dolichosigmoid [Figure 3]. Resection of the sigmoid loop and the creation of a Hartmann-type colostomy were performed. The patient presented perioperative hemodynamic instability requiring resuscitation with vasoactive drugs. Noteworthily of mentioning, in utero fetal death occurred intraoperatively and was confirmed by Doppler ultrasound. The patient was shifted to the intensive care unit. An induction of vaginal labor was carried out on the 2nd postoperative day resulting in the delivery of a stillborn baby with an uneventful postpartum. After a 1-week stay in the intensive care unit, the patient progressed well clinically and biologically, apart from an infection of the abdominal wall which was controlled by local care and appropriate antibiotic therapy. Therefore, the patient was discharged on the 15th postoperative day. Four months later, an uneventful reversal of the Hartmann procedure was performed.
Figure 1: MRI T2-weighted (axial image) showing distended colic loop and narrowing of the sigmoid colon at the transition point (arrow) and fetus (star). MRI: Magnetic resonance imaging
Figure 2: Coronal T2-weighted MRI image showing “whirl” sign compatible with sigmoid volvulus (arrow) and fetus (star). MRI: Magnetic resonance imaging
Figure 3: Preoperative view showing gravid uterus (star) and necrotic volvulated sigmoid (white arrow) with dilated intestinal proximal loops (red arrow) Discussion Digestive obstruction rarely complicates the course of pregnancy. Its prevalence varies between 1/1500 and 1/66,431 deliveries.[3] The most common cause of colonic obstruction is sigmoid volvulus, with an incidence of between 25% and 44%.[4] Historically, the first case of sigmoid volvulus in pregnancy was reported by Braun in 1885.[5] Thereafter, Aftab et al. reported in 2013 a review of the literature that included 95 cases.[1] More recently, Al Maksoud et al. reported 104 cases in another review of the literature published in 2015.[2]
It is commonly accepted that the dolichosigmoid and the congenital absence of the retrocolonic fascia are the two factors, which were widely incriminated in the occurrence of sigmoid volvulus.[6] During pregnancy, in addition to these classical structural factors, the increased volume of the pregnant uterus tends to push the sigmoid colon out of the pelvic cavity and thus facilitates its torsion around the attachment point on the mesosigmoid. This hypothesis could explain the high incidence (75%) during the third trimester when the uterine volume is maximal.
The diagnostic delay varies from 1 h to 6 days with an average duration of 40.6 h.[6] In our patient, this delay amounts to 3 days. A delay in diagnosis beyond 48 h is considered to be the main factor that determines the maternofetal outcome. Indeed, it is correlated with the degree of colonic ischemia and, consequently, systemic sepsis.[7] In the literature review by Aftab et al., six patients among eight maternal deaths have delayed diagnosis of over 72 h.[1] Maternal mortality is 5% if the colon is viable, however, it increases to 50% if the colon is perforated.[8] Fetal mortality in sigmoidal volvulus is approximately 30%.[1] It may be secondary to decreased placental blood flow due to hypovolemia, or increased intra-abdominal pressure following massive sigmoidal dilatation.[9] The clinical and radiological presentation of the obstruction is similar to that of a nonpregnant patient. However, the interpretation of such signs is misleading in the pregnant context. The cause of pelvic pain is difficult to distinguish between abdominal and gynecological origin because of common innervation. In our patient, the first suspected diagnosis was the threat of preterm delivery. Besides, vomiting can be interpreted as a sympathetic sign of pregnancy, especially in the first trimester. Of note, up to 16-week gestation, almost 50% of pregnant women present with nausea and 33% with vomiting.[6] Biologically, the interpretation of hyperleukocytosis is challenging as it is a common physiological finding in the last two trimesters.[10],[11]
Once the diagnosis is suspected, the medical team is faced with a second challenge, which is the choice of imaging diagnosis tool in the context of pregnancy, given the teratogenic risk of fetal irradiation.[10] Abdominal and pelvic ultrasound, a quick and anodyne examination, is carried out as a first-line investigation in painful abdominal and pelvic syndrome. In practice, it is only of obstetrical interest, as it allows fetal vitality to be assessed and a threat of premature delivery to be eliminated. To explore intestinal obstructive syndrome, we know that abdominal computed tomography (CT) is the gold standard examination.[6] It is also of interest that the risk of teratogenesis is minimal during the third trimester, the predilection period for sigmoid volvulus. For these reasons, we believe that the rationale for these worries about teratogenesis is not justified, particularly given the serious maternal–fetal consequences, if the diagnosis is delayed. In any case, practitioners need to keep in mind that maternal prognosis is a priority and that the hesitation to obtain radiological examinations worsens the prognosis. Given these constraints on the use of CT scans, MRI could be an excellent alternative during pregnancy. Its cost-effectiveness is comparable to that of CT.[12] However, it remains an examination that is hampered by the difficulty of its availability in the emergency setting, which may also prolong the diagnostic delay.
The management of sigmoid volvulus in pregnant women requires close collaboration between the gastrointestinal surgeon, obstetrician, neonatologist, anesthetist, and endoscopist. The choice of treatment depends on the gestational age and the condition of the sigmoid colon. In the absence of signs of ischemia, endoscopic detorsion should be attempted, although it should always be kept in mind that endoscopic detorsion, which is successful in around 90% of cases outside of pregnancy,[13] is limited by the volume of the uterus, especially during the third trimester as in our case.[2] Some authors use a gastroscope that seems more flexible and better tolerated without sedation.[14] In the case of failure of endoscopic detorsion or the presence of signs of clinical or radiological gravity (signs of shock or peritonitis), an urgent sigmoidectomy with colostomy should be performed without delay.[9] If adequate colonic exposure cannot be obtained, a cesarean may be discussed. Some authors prefer to perform a primary anastomosis with or without preoperative colonic lavage when there is no contamination of the peritoneal cavity.[9] However, primary anastomosis of a distended and edematous colon should be avoided as it carries additional maternal and fetal risks.
The obstetric decision depends primarily on the fetal status.[2] Pregnancy can be continued until fetal maturation in case of successful endoscopic distortion. In this case, sigmoidal resection can be postponed until after delivery. Vaginal delivery can be attempted, but if cesarean extraction is required, simultaneous sigmoidal resection may be discussed. If in utero fetal death is diagnosed before or during emergent sigmoidal resection, as in our case, some authors advocate simultaneous extraction by cesarean section. This approach carries a high risk of puerperal infection. In our case, we have opted for induction of labor with postoperative vaginal delivery to reduce the risk of infection and to shorten the operative procedure of sigmoidal resection.
ConclusionSigmoidal volvulus during gestation is a rare but potentially serious entity. Improvement of maternal–fetal prognosis is based on early diagnosis, which requires a high index of suspicion regarding symptoms mimicking an occlusive syndrome. Management requires close multidisciplinary collaboration.
Author's contributions
All of the authors were involved in the preparation of this manuscript. TS was the surgeon and has made substantial contributions to the conception, bibliography, and drafting of the manuscript. TO was the surgeon's assistant and is involved in the drafting of the manuscript. BA provided and described radiological findings and is involved in the drafting of the manuscript. All co-authors read and approved the final manuscript. While further edits of the manuscript and comments were done by TS.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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