Rare disease
CASE REPORT
Twin pregnancy complicated with bowel strangulation Tze Fang Wong,1 Shunichi Imai,2 Masato Tomita3 1
International Goodwill Hospital, Yokohama, Japan 2 Department of General Surgery, Keio University, Tokyo, Japan 3 Department of General Surgery, International Goodwill Hospital, Yokohama, Kanagawa, Japan Correspondence to Dr Tze Fang Wong, mariawongtzefang@ marianna-u.ac.jp Accepted 18 August 2014
SUMMARY A 31-year-old primigravida at 35 weeks of gestation with twins who had no prior abdominal surgical history presented with worsening nausea, vomiting and abdominal pain. Initial screening ruled out obstetrical causes that may threaten the pregnancy. Twelve hours after the onset of symptoms, a transabdominal ultrasound revealed abdominal free fluid. A CT scan confirmed strangulated ileus involving the small bowels. Owing to non-reassuring fetal status in one of the twins, an emergency caesarean section and subsequent laparotomy were performed. The first twin presenting with fetal distress had to be resuscitated postdelivery but recovered uneventfully and met all developmental milestones by 3 months of age. The mother had a strangulated small bowel that had to be resected. She had an uncomplicated postsurgical course and gained full bowel function prior to discharge from the hospital.
INVESTIGATIONS
Acute abdomen in pregnant women poses an additional challenge in diagnoses due to the anatomical changes during pregnancy and limitations in diagnostic imaging. Abdominal and vaginal ultrasonography is usually the first-line of definitive investigation thanks to the low risk of radioactive exposure. Ultrasonography is especially useful in ruling out placental abruption, uterine rupture, adnexal torsion and hydrocalyx associated with pyelonephritis, but can be more limited in the diagnosis of diseases of the gastrointestinal tract. Combined with the appropriate laboratory work-ups such as liver function tests and urinalysis, pre-eclampsia, haemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome, or acute fatty liver of pregnancy that may mimic an acute abdomen could also be diagnosed. Despite careful diagnostic work-up using conventional means, some life-threatening illnesses may still be missed. We present a case with twin pregnancy that was complicated by an acute abdomen, whose diagnosis using a CT scan prompted an emergency caesarean section and laparotomy that saved the lives of the mother and the twin neonates.
Laboratory tests revealed amylase 136 IU/L (normal range 40–126 IU/L), lactate dehydrogenase (LDH) 230 IU/L (normal range 119–229 IU/L) and creatine kinase (CK) 555 IU/L (normal 20–170 I/L). She had an elevated D-dimer 4.3 μg/mL (normal 500 mL on the third day of management were, respectively, OR 5.2 (95% CI 1.9 to 14.2; p
CASE REPORT
Twin pregnancy complicated with bowel strangulation Tze Fang Wong,1 Shunichi Imai,2 Masato Tomita3 1
International Goodwill Hospital, Yokohama, Japan 2 Department of General Surgery, Keio University, Tokyo, Japan 3 Department of General Surgery, International Goodwill Hospital, Yokohama, Kanagawa, Japan Correspondence to Dr Tze Fang Wong, mariawongtzefang@ marianna-u.ac.jp Accepted 18 August 2014
SUMMARY A 31-year-old primigravida at 35 weeks of gestation with twins who had no prior abdominal surgical history presented with worsening nausea, vomiting and abdominal pain. Initial screening ruled out obstetrical causes that may threaten the pregnancy. Twelve hours after the onset of symptoms, a transabdominal ultrasound revealed abdominal free fluid. A CT scan confirmed strangulated ileus involving the small bowels. Owing to non-reassuring fetal status in one of the twins, an emergency caesarean section and subsequent laparotomy were performed. The first twin presenting with fetal distress had to be resuscitated postdelivery but recovered uneventfully and met all developmental milestones by 3 months of age. The mother had a strangulated small bowel that had to be resected. She had an uncomplicated postsurgical course and gained full bowel function prior to discharge from the hospital.
INVESTIGATIONS
Acute abdomen in pregnant women poses an additional challenge in diagnoses due to the anatomical changes during pregnancy and limitations in diagnostic imaging. Abdominal and vaginal ultrasonography is usually the first-line of definitive investigation thanks to the low risk of radioactive exposure. Ultrasonography is especially useful in ruling out placental abruption, uterine rupture, adnexal torsion and hydrocalyx associated with pyelonephritis, but can be more limited in the diagnosis of diseases of the gastrointestinal tract. Combined with the appropriate laboratory work-ups such as liver function tests and urinalysis, pre-eclampsia, haemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome, or acute fatty liver of pregnancy that may mimic an acute abdomen could also be diagnosed. Despite careful diagnostic work-up using conventional means, some life-threatening illnesses may still be missed. We present a case with twin pregnancy that was complicated by an acute abdomen, whose diagnosis using a CT scan prompted an emergency caesarean section and laparotomy that saved the lives of the mother and the twin neonates.
Laboratory tests revealed amylase 136 IU/L (normal range 40–126 IU/L), lactate dehydrogenase (LDH) 230 IU/L (normal range 119–229 IU/L) and creatine kinase (CK) 555 IU/L (normal 20–170 I/L). She had an elevated D-dimer 4.3 μg/mL (normal 500 mL on the third day of management were, respectively, OR 5.2 (95% CI 1.9 to 14.2; p
