Case Report

Precipitous decline of Gravid patient with congenital small bowel malrotation

Abstract

Congenital small bowel malrotation is an uncommon cause of ischemic bowel. There are only a few case reports highlighting this condition in gravid patients. We report a 33-year-old primigravida at 27 weeks who presented to the emergency department with diffuse abdominal pain. Although initially stable, she experienced a rapid calamitous decline. On laparatomy she was diagnosed with congenital small bowel malrotation. Intraabdominal catastrophes must always be considered as a possible etiology of nonobste- trical abdominal pain in pregnant women.

A 33-year-old primigravida presented at our emergency department at 27 weeks of gestation with a primary complaint of intermittent, crampy, ill-defined abdominal pain. She was previously healthy with only a long-standing history of constipation. Vital signs were blood pressure of 130/80 mm Hg, heart rate of 90 beats per minute, and temperature of 36.5?C. Her abdomen was nontender with no evidence of guarding or rebound. The obstetrical service- performed electronic fetal monitoring demonstrating a reactive, reassuring tracing with no evidence of uterine contractions. Urinalysis had negative results, and laboratory studies including complete blood count, Liver enzymes, amylase, and electrolytes were normal. It was requested that she be monitored in the emergency department overnight for obstetrical reassessment in the morning.

Within 4 hours, the patient deteriorated significantly and was in severe distress. Her blood pressure decreased to 90/60 mm Hg and her heart rate increased to 140 beats per minute. Her abdomen had marked diffuse tenderness. The emergency physician performed obstetrical ultrasonography and found a nonviable fetus.

The white blood cell count had increased from 15 000/mm³ to 23 700/mm³, with a Neutrophil count of 20 700/mm³. The only change in her electrolytes was a slight decrease in her bicarbonate from 22 to 20 mmol/L. liver enzyme levels were still within normal limits. A Kleihauer-Betke test showed no fetal cells. The attending obstetrician entertained

a provisional diagnosis of placental abruption with a differential diagnosis of intraabdominal catastrophe and transferred the patient to the maternity unit. Urgent delivery was attempted through a trial of induction. However, the patient’s worsening clinical picture necessitated immediate operative delivery.

Laparotomy revealed midgut malrotation with complete necrosis of the small bowel from the ileocecal valve to the duodenum. Intraoperatively, 2 general surgeons were con- sulted. They recommended that the bowel was not salvage- able and that palliative management should be undertaken.

intestinal obstructions complicate 1 in 1500 to 1 in 66 000 pregnancies [1]. They are primarily caused by adhesions (60%-70%) but can also be secondary to intussusception, hernias, neoplasms, or volvulus, half of which involve the small bowel [2-4]. In a series of 66 patients with pregnancy complicated by obstruction, 15 required surgery, with a Maternal mortality of 6% and a fetal mortality of 26% [5].

Volvulus is a consequence of the intestine rotating about its mesenteric axis, eventually resulting in a closed-loop obstruction. The major sites of volvulus are the sigmoid colon and the small bowel [6,7]. Conditions implicated in the development of volvulus include adhesions, congenital bands, Meckel diverticulum, and hernias. The uterus enlarges most rapidly between 16 to 20 weeks and again between 32 to 36 weeks, and obstruction occurs most frequently at these times [8,9].

Clinical presentation of small bowel volvulus is due to both the mechanical obstruction and the vascular compro- mise with resultant ischemic bowel. initial symptoms are similar to those common in pregnancy, including crampy abdominal pain, nausea, vomiting, and constipation, fre- quently delaying definitive diagnosis. Classical findings of bowel obstruction in the nonpregnant patient, including obstipation, altered bowel sounds, and peritoneal signs, are frequently obscured by the gravid uterus [7-9].

Laboratory findings may include an elevated white blood cell count, electrolyte derangement, and lactic acidosis, although this often is a late finding. In a nongravid patient, the diagnostic test of choice is computed tomography, which has sensitivity of 93%, specificity of up to 100%, 94% accuracy, and is superior to ultrasonography and Plain radiography [10]. Although the above findings have only

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been conclusively demonstrated in nonpregnant patients, they can probably be used in pregnant patients as well. Although there are medicolegal ramifications involved in radiographic imaging of the gravid patient, for an acute Abdominal emergency, the benefits to both the fetus and the mother probably outweigh the fetal risk. Irradiation will have the greatest harm early in gestation-the most susceptible time occurs during the development of the neurologic system between the 8th and 25th gestational weeks. An Abdominal computed tomography exposes the fetus to approximately 3 rads [11,12]. This is within an acceptable range in late trimester pregnancies.

Because of the dose of fetal radiation involved, magnetic resonance imaging is a reasonable imaging alternative. Although there is a paucity of literature in pregnant patients, magnetic resonance imaging is comparable to small bowel enteroclysis in the diagnosis of obstruction [13]. Magnetic resonance imaging has also been used to diagnose a high-grade Small bowel obstruction in a Third trimester pregnancy [14].

In most prior case reports, intestinal obstruction was diagnosed on clinical or radiologic grounds after an admission. A precipitous decline as seen in our patient has not been previously noted. While evaluating nonspecific abdominal pain in the emergency department, fetal monitoring is recommended for the gravid patient [4,9,15]. An abnormality in the tracing may be the initial indicator of a serious cause of abdominal pain [16]. Although fetal monitoring by telemetry has been in use for decades [17], few emergency departments have access to this technology.

Frank Scheuermeyer MD, MHSc Department of Emergency Medicine St Paul’s Hospital, Vancouver Canada BC V6Z 1Y6

E-mail address: [email protected] doi:10.1016/j.ajem.2008.08.034

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