British Journal of Obstetrics and Gynaecology May 1979. Vol. 86. pp 41 1-413

PSEUDO-OBSTRUCTION OF THE BOWEL IN PREGNANCY CASE REPORTS BY

E. J. SHAXTED Registrar in Obstetrics and Gynaecology Addenbrooke’s Hospital AND

R. JUKES Senior House Officer in Obstetrics Mill Road Maternity Hospital, Cambridge Summary Two patients with intestinal obstruction in pregnancy are presented and discussed. In neither case was there any obvious cause for the intestinal obstruction. Pseudoobstruction of the bowel has not previously been described as a complication of pregnancy.

THEacute abdomen is always a difficult diagnostic problem in pregnancy and intestinal obstruction is a rare, and frequently undiagnosed cause of pain (Morris, 1965). Various causes of intestinal obstruction complicating pregnancy have been described including adhesions (Svesko and Pisani, 1960) volvulus, intussusception and tumours of the bowel. Pseudo-obstruction is a diagnosis made by exclusion and has been described as ‘where the symptoms and signs of mechanical intestinal obstruction are present, but on further investigation, or at operation, no obstruction is found’ (Leading Article, 1973). A variety of associated illnesses have been described : these include renal failure, cardiac failure and myocardial infarction (Leading Article, 1973). We are not aware of any association between pregnancy and pseudoobstruction, but a similar occurrence has been described after Caesarean Section (Anthony and Wallace, 1962).

CASE. REPORTS

Patient 1 A 25-year-old presented to her general practitioner at 34 weeks gestation in her second pregnancy with right sided abdominal pain. Her previous pregnancy had been uneventful and ended at 40 weeks with a normal delivery. There was no past history of abdominal pain, constipation or abdominal surgery. The initial diagnosis was of urinary tract infection and the patient was treated in the General Practitioner Maternity Unit with ampicillin. A mid-stream specimen of urine was sterile. After three days the pain became more intense and colicky in nature. The patient vomited and became more distended with absolute constipation. She was transferred to the Consultant Unit and a diagnosis of intestinal obstruction was made on clinical and radiological signs. The patient was treated with intravenous fluids and nasogastric suction. After 24 hours she had a laparotomy.

* Present address: Senior House Officer, Guy’s Hospital, London. 41 1

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At laparotomy the large bowel was widely dilated as far as 8 cm below the splenic flexure where the calibre was normal again. There were no adhesions, no volvulus, intussusception or tumour. There were no sign j of peritonitis. The caecum was grossly distended with some tearing of the serosal peritoneum. The large bowel was decompressed and a caecostomy performed. After 24 hours spontaneous labour ensued and a male infant weighing 2.350 g was delivered under epidural block with Kielland’s forceps. A subsequent barium enema has shown the large bowel to be normal to the site of the caecostomy and the latter was formally closed one month after laparotomy. The patient has since been asymptomatic but there has been no further pregnancy. Patient 2 A 24-year-old woman was admitted at 27 weeks gestation in her second pregnancy, for rest because of a twin pregnancy. Her first pregnancy had been terminated for social reasons at ten weeks. There was a past history of meningitis, appendicitis and jaundice. The maturity of the present pregnancy had been confirmed by ultrasound at thirteen weeks and at which time twins had been diagnosed. Following admission the patient complained of epigastric discomfort which responded to antacids. A glucose tolerance test, performed because of a family history of diabetes, showed gestational diabetes and the patient was treated with a 150 g carbohydrate diet. At 29 weeks gestation, uterine contractions were noted and the patient was started on oral salbutamol. At 30 weeks these contractions became more intense and required intravenous salbutamol. The uterine contractions ceased but the patient vomited and developed abdominal distension with increasingly severe abdominal pain. The clinical signs were those of intestinal obstruction, and an abdominal X-ray revealed dilated loops of bowel. Conservative management with intravenous fluids and nasogastric suction was started. After 24 hours the pain became more severe and uterine contractions recommenced. Laparotomy was performed. At operation the twins were delivered by routine lower segment Caesarean section and

weighed 1.4 kg and 1 a 3 kg. The transverse and descending colon were grossly dilated down to the level of the pelvic brim. The rectum was empty and collapsed. There were no adhesions, volvulus or other obvious cause for the obstruction. The bowel was deflated with a tube passed per rectum and the wound was closed in the usual position. Postoperatively, the patient showed clinical signs of obstruction for four days but then made a good recovery. A subsequent sigmoidoscopy has been normal and the patient is now asymptomatic. COMMENT The most common cause of intestinal obstruction in pregnancy appears to be adhesions (Svesko and Pisani, 1960; Morris, 1965) and occurs most commonly between the fifth and eighth months of pregnancy (Goldthorpe, 1966). Compression of the large bowel by an incarcerated uterus after delivery has been described (Anthony and Wallace, 1962). It may be that this was a factor in patient 2, with a large uterus compressing the bowel at the pelvic brim. If, however, this was the case it seems strange that it is not a common event. A variety of drugs were also being taken by patient 2. We do not, however, know of any previous cases where salbutamol or antacids have caused obstruction of the bowel. In patient 1, the bowel was distended to a degree where rupture seemed likely, hence the defunctioning caecostomy. This feature has been described by other authors in intestinal obstruction in pregnancy (Anthony and Wallace, 1962; Morris, 1965). One of the problems of diagnosing intestinal obstruction in pregnancy, is that vomiting and constipation, together with vague abdominal pains are so common. Nevertheless, had these patients not been pregnant, operation might have been performed sooner; in other patients described, excessive delay has proved fatal (Morris, 1965). At the time of surgery, delivery by Caesarean Section may be required to allow a proper laparotomy. This was the case in patient 2. In any event, premature labour was probably precipitated by surgery in patient 1 and nothing was gained by not delivering the baby abdominally.

PSEUDO-OBSTRUCTION

ACKNOWLEDGEMENT We thank Mr M. J. Hare for permission to report patient 2 and for his help in preparing the paper.

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REFERENCES Anthony, A., and Wallace, J. T. (1962): New York State Journalof Medicine, 62,3462. Goldthorae. W. (1966):British JournalofClinicaIPractice. 20,367.' . . Leading Article (1973): British Medical Journal, 1,64. Morris, E. D. (1965): Journal of Obstetrics and Gynaecology of the British Commonwealth, 72,36. Svesko, V., and Pisani, B. (1960): American Journal of Obstetrics and Gynecology, 79,157.

Pseudo-obstruction of the bowel in pregnancy: case reports.

British Journal of Obstetrics and Gynaecology May 1979. Vol. 86. pp 41 1-413 PSEUDO-OBSTRUCTION OF THE BOWEL IN PREGNANCY CASE REPORTS BY E. J. SHAX...
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