Clinical Presentation of Intestinal Obstruction in Pregnancy and Management Challenges: Case Series

    

    

    Figure 3: Healed midline incision with colostomy in situ.
    

Case 2

A 39-year-old G10P9L9 with a gestation age of 23 weeks presented with a 3-day history of sudden onset of abdominal pain associated with distension, absolute constipation and vomiting after every oral intake. There were no significant past medical or surgical history. Her previous obstetric history was essentially uneventful with all previous vaginal deliveries. On general examination, she was ill-looking, mildly pale, mildly dehydrated and febrile to touch. Her initial blood pressure was 140/82 mmHg, axillary temperature of 37.7oC, pulse rate of 122 beats/min, respiratory rate of 20 breaths per cycle saturating at 96% on room air. She has a naso-gastric tube that was draining dark gastric contents. Her abdomen was grossly distended with generalized abdominal pain, absent bowel sounds and a positive blumberg sign. Routine blood tests revealed leukocyte count of 15.40 x 109/L, haemoglobin of 8.0 g/dl and a platelet count of 224 x 109/L, serum sodium of 134.92 mmol/l, potassium of 2.44 mmol/l, serum creatinine of 39 umol/l, BUN of 4.56 mmol/l and liver enzymes within range.

An abdominal ultrasound revealed dilated bowel loops with intraluminal free fluid & internal echoes, prominence of valvulae conniventes, extra luminal free fluid and insufficient peristalsis movements. The uterus was gravid with a single-tone pregnancy of 23 weeks. A diagnosis of small bowel obstruction with peritonitis in pregnancy was made. An emergency laparotomy was performed revealing approximately one litre of foul smelling hemorrhagic ascites and twisted terminal ileum around its mesentery. Approximately 40cm of the terminal ileum was gangrenous including the ileocecal junction, and a fecaloma was found in the ascending and transverse colon. . The gangrenous segment of the bowel was resected, ileocaecal junction closed, ileostomy raised, lavage done and the fascia was closed but the skin was left open. The resected terminal ileum was sent for histology analysis which was insignificant. A drain was left in situ and the patient received 450mls of whole blood intraoperatively.

Post operatively, the patient was nursed in the surgical ICU and the obstetric team initiated Indomethacin 25mg twice daily for 24 hours for tocolytic effect. The Fetal Heart rate (FHR) was 124 bpm. The patient started oral sips on the day-3 post operative and was tolerating feeds well. On day she developed a burst abdomen and was prepared for re-laparotomy. The abdomen cavity was thoroughly cleaned, the ileostomy was refashioned and tension-sutures were applied. She received 450 mls of whole blood. She continued to fair well in the general surgery unit and was discharged after 18 days with gestational age of 27 weeks and 1 day. Prior discharge she was reviewed by the obstetrician and obstetric ultrasound was uneventful with fetal heart rate of 142.

After a week she attended her routine ANC clinic, whereby she was moderately pale, mildly sclera jaundiced and had bilateral lower limb non-tender pitting edema. Her blood pressure measured 97/46 mmHg, pulse rate of 123 beats per minute and saturating at 97% on room air. She was admitted to the obstetric ward with a diagnosis of high risk pre-term pregnancy not in labor. Her blood work revealed hemoglobin of 8 g/dl, platelets of 108 x 109/l, sodium 127 mmol/l and potassium of 3.7mmol/l, AST of 23.31 U/l and ALT 10.67 U/l. Dexamethasone was initiated at 6gm twice daily for 2 days for maturation of fetal lungs and she received 2 units of whole blood during her stay. The ileostomy was patent and the midline incision clean and dry. The patient was then discharged after 2 days on oral iron and ferrous supplements and her control hemoglobin was 9.6 g/dl.

Four weeks later, she attended ANC whereby her ultrasound revealed gestation age of 31 weeks with adequate amniotic fluid. She was not jaundiced and not pale with resolved lower limb edema. Her ileostomy was functioning well and was discharged. She delivered her baby at a peripheral hospital hence details of the gestation age, newborn’s vitals and weight were not obtained.

She was then admitted two months post delivery for ileostomy closure. Her haemoglobin was 10.1 g/dl, platelet count of 258 x 109/L and normal serum sodium and potassium levels. Intraoperatively multiple adhesions were encountered, small bowel was atrophied, transverse colon with fecaloma in the ileostomy was mobilized, adhesiolysis performed and standard right hemicolectomy done. Ileal-transverse end-to-end anastomosis and lavage done, abdominal drain was left in situ. During her stay in the ward, patient has an uneventful recovery and was discharged 4-days post laparotomy and was scheduled to visit the surgical out-patient clinic after 2 weeks but the patient was lost to follow-up.

Case 3

A 34-year-old female, G7P6L5 was admitted at the obstetrics department in her 29th week of pregnancy by booking, with complaints of sudden onset of left upper quadrant abdominal pain for 2 weeks. She past medical and surgical history was uneventful and delivered previously vaginally. On general examination, the patient was moderately pale, alert, Abdominal examination revealed tenderness on the left upper quadrant, a gravid uterus at a fundal height of 29 weeks, and fetal heart rate of 142 beats per minute.

Obstetrics ultrasound recorded a biophysical profile of 8/8 with the placenta lying fundal anterior. A full blood count on admission reported hemoglobin of 6.4g/dl, normal leucocyte and platelet counts. She tested negative for malaria and HIV. Second day in the ward she started having recurrent feculent vomiting associated with absolute constipation. Her plain abdominal x-ray revealed multiple air-fluid levels with empty rectum in pregnancy. She was kept nil orally, catheterized, and a nasogastric tube was inserted. Her blood work reported normal electrolyte count, serum sodium of 135.11mmol/l and potassium of 3.38mmol/l. An emergency laparotomy was performed. Intraoperative findings included clear peritoneal fluid with gravid uterus, ileal-ileal intussusception of 60 cm telescoped, about 160 cm from the ileocecal junction, a constricting tumor like mass and enlarged mesenteric lymph nodes. The tumor was resected with 5 cm on each side, an ileo-ileal end-to-end anastomosis was done, patency was established and vent was closed. Lavage was done and the abdomen was closed in layers. The sample was sent for histopathology that concluded well differentiated invasive adenocarcinoma of the ileum (pT2N0Mx) with free margins. She received 450 mls of whole blood intra-operatively and another 450 mls post operatively. A post operative diagnosis of Intestinal obstruction secondary to an intussusception due to an ileal tumor was established.

The patient had an uneventful recovery and was discharged on the 13th day post operative whereby she reported positive fetal kicks and was tolerating meals. She was then reviewed after four weeks at the surgical out-patient unit whereby she was clinically stable, not pale and tolerating oral feeds well with no constipation. She was on oral hematinics. Unfortunately she was later lost to follow up.

Case 4

A 24-year-old female, prime gravid with a gestational age of 20 weeks by dates, was referred to our centre due to six day history of generalized abdominal pain that was of sudden onset and progressive and aggravating by taking oral meals. This was associated with nonprojectile vomiting and not passing stools. She denied abdominal trauma and did not experience any vaginal discharge during the course of her illness. Her past medical history was uneventful. She has been attending antenatal clinic, received iron and folate supplements and been tested negative for HIV and malaria. She has been reported to have normal blood sugars and blood pressures.

Upon examination, she was fully conscious, mildly pale with no lower limb edema. She has a nasogastric tube in situ that was draining gastric contents. Her BP measured 100/72 mmHg, pulse was 122, axillary temperature of 36.4oC and saturation at 94% on room air. Her abdomen was grossly distended with no scars, generalized tenderness with a palpable gravid uterus and exaggerated bowel sounds on auscultation. Rectal examination revealed empty rectum and other systems were essentially normal. Her leucocyte count was 19 x 109/L, haemoglobin of 8 g/dl and a normal platelet count. Her serum creatinine was 30 μmol/L and BUN of 1.70 mmol/L. She had an abdominal ultrasound that showed dilated bowel loops, abdominal x-ray showed dilated bowels with no air-fluid levels and chest x-ray was normal (Figure 4).

    

    

    Figure 4: X-ray showing no chest abnormalities with some dilated loops.