March 2009.indd SQU MED J, APRIL 2009, VOL. 9, ISS. 1, PP. 84-88, EPUB 16TH MAR 2009 SUBMITTED - 28ST JUNE 08 REVISION REQ. 19TH AUG 08, REVISION RECD. 26TH AUG 08, ACCEPTED - 13TH SEPT 08 ABSTRACT Sigmoid volvulus is an extremely rare cause of intestinal obstruction in pregnancy. The rarity of the condition and the fact that pregnancy itself clouds the clinical picture invariably leads to a delay in diagnosis with an increased risk of gangrene of the gut. The majority of these patients would then require resection and colostomy. However, an early diagnosis and intervention as in our patient, which would require a high index of clinical suspicion, could significantly improve the outcome of the foetus and the mother. A case of sigmoid volvulus in pregnancy is reported which was managed by resection and primary anastomosis. A review of literature revealed no previous reports of sigmoid volvulus in pregnancy managed by primary anastomosis following resection of the sigmoid volvulus. The literature is also reviewed regarding predisposing factors, management options and the outcome of sigmoid volvulus complicating pregnancy. Key words: Sigmoid volvulus; Pregancy; Resection; Case report; Oman; Sigmoid Volvulus Complicating Pregnancy Managed by Resection and Primary Anastomosis Case report with literature review *Norman O Machado,1 Lovina S M Machado2 INTESTINAL OBSTRUCTION, WHICH IS RARE IN pregnancy, has a reported prevalence of 1 in 1,500 to 1 in 66,431 pregnancies.1-3 Sigmoid vol- vulus contributes to 12% of these cases.3 The essential problems of sigmoid volvulus in pregnancy are those of delay in presentation and diagnosis. Delay in diag- nosis invariably leads to ischaemia of the colon, which warrants resection and colostomy as noted in most of the reported cases.1-5 Prompt surgical intervention is necessary to minimise maternal and foetal morbidity and mortality. The reported maternal mortality is 6% with a foetal mortality of 26%.3 C A S E R E P O R T A 24 year old lady, gravida 2, para 1 presented at 18 weeks gestation with complaints of intermittent ab- dominal pain and recent onset of worsening lower abdominal distension over 12 hours. Her pregnancy had been otherwise uneventful. She had no previous medical problems or prior abdominal surgery. On ex- Department of 1Surgery, 2Obstetrics and Gynaecology, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman *To whom correspondence should be addressed. Email: norman@omantel.net.om ومعاجلته باالستئصال احلمل خالل ينِيّ تالٌ السِّ االِنْفِ مضاعفات األولي والتفاغر أدبيات مع مراجعة حالة تقرير ماتشادو لوفينا ماتشادو، نورمان يؤخر التشخيص السريري للوضع احلمل تشويش إضافة إلى احلالة هذه ندرة . الوالدة أثناء األمعاء جدا النسداد حالة نادرة ينِيّ السِّ تال االِنْفِ امللخص: رُ فَغْ و من األمعاء املصاب استئصال اجلزء يحتاج غالبية املرضى إلى السبب لهذا . األمعاء بغنغرينة باإلصابة االختطار إلى زيادة مما يؤدي على األغلب عالية من درجة إلى يحتاج وهذا ، مبكرا والتدخل ــخيص التش إذا مت واجلنني فيما لألم ــبة بالنس النتيجة ــني حتس ، ميكن أخرى جهة من لكن . ولون القَ التي حلالتنا حالة مشابهة جند لم الطبية مراجعة األدبيات بعد . األولي باالستئصال والتفاغر عوجلت ــينِيّ تالٌ سِّ اِنْفِ حالة هنا ندرج . ــك والش احلذر مع أثناء احلمل ــينِيّ السِّ تال لالِنْفِ املؤهبة العوامل حول األدبيات الطبية مراجعة متت كذلك ــة. املصاب ــتئصال املنطقة اس بعد األولي التفاغر ــا مت فيه . والنتائج العالج طرق عمان. حمل ، استئصال ، تقرير حالة ، الكلمات: انفتال سيني ، مفتاح C A S E R E P O R T S I G M O I D VO LV U L U S C O M P L I C AT I N G P R E G N A N C Y M A N A G E D B Y R E S E C T I O N A N D P R I M A R Y A N A S T O M O S I S 85 amination, she was afebrile and had mild generalised abdominal tenderness. Her abdomen was distended with the gravid uterus corresponding to 18 weeks size and a gas-filled gut. Routine laboratory studies were significant only for an elevated white blood cell count of 13,500 x 109/L, which could have been due to normal physiological response in pregnancy. In view of her pregnancy, no radiological examinations were performed. She was admitted for close observation and given a fleet enema with no result and no effect on her ab- dominal pain or distension. Over the next 6 hours the abdominal pain continued to worsen, relieved partial- ly by narcotic analgesics. The abdomen was distended, soft, hyperesonant and hyperperistalitic. A diagnosis of sigmoid volvulus was then entertained as the ab- dominal distension was predominantly in the lower abdomen and progressed along with colicky abdomi- nal pain. Obstetric assessment revealed an active foe- tus and there were no signs of threatened abortion. After informed consent, and 8 hours after admis- sion, the patient was prepared for an attempt at sig- moidoscopic detorsion, with a possibility of laparot- omy in the event of failure. Sigmoidoscopy confirmed the obstruction due to a twist in the sigmoid colon; however, the attempt to negotiate the obstruction failed, necessitating laparotomy through a lower mid- line incision. The sigmoid colon was grossly distended Table 1: Reported cases of sigmoid volvulus in pregnancy Author Between Year Number of Cases Reviewed Gestational age in Weeks Duration initial symptoms & management (in Hours) Present Study 2006 1 18 18 Alshawi12 2005 1 28 & 35 (Recurrent) <24 De U et.al.8 2005 1 24 >72 Joshi et.al.9 1999 1 28 >48 Lurie et.al.13 1997 1 ectopic Pregnancy 36 Lord et.al.6 1996 1 36 >24 Allen.14 1990 1 28 >12 Keating et al.5 1985 1 34 12 Hofmeyr et al.10 1985 2 33 >48 26 >48 Fraser et al.11 1983 1 32 >12 Lazaro et al.2 1958-1969 13 - - Harer & Harer.4 Before 1958 52 - - Figure 1: Sigmoid volvulus showing grossly dilated, viable sigmoid colon N O R M A N O M A C H A D O A N D L O V I N A S M M A C H A D O 86 but viable. A 180 degree anticlockwise twist was no- ticed [Figure 1]. In view of the proximal colon being relatively empty and the sigmoid colon viable [Figure 2], a resection of the sigmoid colon was performed [Figure 3] with primary anastamosis in 2 layers with vicryl. The patient had an uneventful postoperative re- covery and was discharged on the fifth postoperative day. She has been symptom free since then and had a spontaneous vaginal delivery of a normal healthy male baby at 38 weeks of gestation. D I S C U S S I O N A review of medical literature in English revealed 75 cases of sigmoid volvulus in pregnancy [Table 1] since the first case was reported in 1885.2-14 Rare as the condition is, it is the second commonest cause of intestinal obstruction in pregnancy and a high index of clinical suspicion needs to be maintained to achieve an early diagnosis.1, 3 Several previously described cases of volvulus in pregnancy were found at laparotomy to have pre- disposing causes including adhesions, previous salp- Author Sigmoid colon Treatment Outcome Foetus Patient Present study viable Sigmoid colectomy & primary anastomosis healthy good Alshawi12 viable Sigmoidoscopic detorsion in pregnancy Elective sigmoid colectomy post delivery healthy good De u8 gangrenous Hartman’s procedure IUFD good Joshi M9 gangrenous Hartman’s procedure IUFD good Lurie13 viable Laparotomy & detorsion ectopic good Lord6 gangrenous Hartman’s procedure healthy good Allen14 viable Sigmoidoscopic decompression healthy good Keating5 viable Sigmoid colectomy & double barrel colostomy healthy good Hofmeyr10 gangrenous Hartman’s procedure IUFD good gangrenous Hartman’s procedure IUFD dead Fraser11 viable Laparotomy & detorsion healthy good Legend: IUFD = intrauterine foetal death Table 2: Management and outcome of sigmoid volvulus in pregnancy (series since 1983) Figure 2: Sigmoid volvulus partly decompressed and the gravid uterus (arrow) Figure 3: Resected sigmoid colon S I G M O I D VO LV U L U S C O M P L I C AT I N G P R E G N A N C Y M A N A G E D B Y R E S E C T I O N A N D P R I M A R Y A N A S T O M O S I S 87 ingitis and abnormalities in gastrointestinal tract development.2-5 The patient described here showed none of these features other than a redundant sigmoid loop and a narrow base of the mesocolon. The mecha- nism of sigmoid volvulus in pregnancy has been sug- gested to be due to displacement, compression and partial obstruction of an abnormally mobile sigmoid colon by the enlarging uterus.4 This could probably ex- plain the increased incidence of sigmoid volvulus in the third trimester.3, 7 Eight of the 11 recent cases since 1983 were in the third trimester. Diagnosis of the condition is often delayed. The average length of time from the onset of obstructive symptoms until presentation is reported to be 48 hours.3 This is mainly because pregnancy itself clouds the clinical picture since abdominal pain, nausea, and leukocytosis can occur in an otherwise normal pregnancy.5 In addition, the reluctance to obtain ra- diological evaluation in pregnancy may contribute to diagnostic delay. Among the 11 recent cases, the average duration between the start of symptoms and definitive treat- ment was 32 hours. Of these 11 patients, 4 (36%) were managed after 48 hours of obstructive symptoms.8-11 All these four patients delivered a dead foetus and there was one maternal mortality among them. It was also noted that these four patients had a gangrenous sigmoid colon and underwent Hartman’s procedure and colostomy.8-10 In contrast, the 6 patients, includ- ing the present case, who were managed within 24 hours of initial symptoms had good foetal and ma- ternal outcomes.5,6,11,12,14 Moreover, they were amena- ble to lesser invasive procedures like sigmoidoscopic detorsion.12, 14 or surgical interventions without colos- tomy like laparotomy and sigmoidopexy11 or, as in our case, resection and primary anastomosis. A literature review revealed no previous reported case of primary anastomosis following resection [Table 2]. The management of sigmoid volvulus in the preg- nant patient involves aggressive fluid resuscitation, decompression of the proximal bowel and recognition of this entity as an acute surgical emergency.3,5,6 In the absence of peritoneal signs or mucosal ischaemia, it would seem reasonable to attempt detorsion and de- compression via sigmoidoscopic placement of a soft rectal tube.12, 14 Alshawi12 proposed the following man- agement options based on the stage of pregnancy: in the absence of signs of peritonitis in the first trimester of pregnancy, a nonoperative procedure with colono- scopic detorsion and rectal tube decompression is rec- ommended. This can be repeated in recurrent cases until the second trimester when sigmoid colectomy is recommended. Since continuing with the nonopera- tive approach until foetal maturity is reached is asso- ciated with a high recurrence rate, and surgery in the second trimester reduces the miscarriage rate, elective sigmoid colectomy is recommended in the second tri- mester. It is technically difficult to operate in the pel- vis in the third trimester. Hence it is acceptable to do colonoscopic detorsion and tube decompression until foetal maturity, when elective labour followed by sig- moid colectomy would provide a definitive treatment. Although colonoscopic detorsion is often successful in non-pregnant patients, successful use of this approach in late pregnancy is rarely reported.12,14 This could probably be due to the large gravid uterus acting as a mechanical impediment to detorsion. When surgical intervention is required in these patients, a standard midline incision allows maximal exposure with minimal uterine manipulation. The non-viable bowel is resected with a diverting colos- tomy performed, the stomata being sited away from an elective area of a possible caeserean section.5 Pri- mary anastomosis of an unprepared distended paretic and oedematous large bowel is generally avoided as it could be hazardous to both mother and foetus.5 This is particularly so when there has been a significant delay in establishing a diagnosis. Early diagnosis, however, would make resection and primary anastomosis a safe approach, as in our patient, with the distinct advan- tage of reduced hospital stay and avoidance of further surgery C O N C L U S I O N Sigmoid volvulus complicating pregnancy is an un- common and potentially devastating development. Early diagnosis mandates a high index of clinical sus- picion in a patient who presents with complaints of abdominal pain of increasing severity associated with lower abdominal distension. Delay in diagnosis and treatment beyond 48 hours results in increased foetal and maternal morbidity and mortality. Prompt inter- vention is necessary to minimise these complications and achieve a definitive cure. R E F E R E N C E S 1. Coughlan BM, O’Herlihy CO. Acute intestinal obstruc- tion during pregnancy. J R Coll Surg Edinb 1978; 23:175- 7. N O R M A N O M A C H A D O A N D L O V I N A S M M A C H A D O 88 2. Lazaro EJ, Das PB, Abraham PV. Volvulus of the sig- moid colon complicating pregnancy. Obstet Gynecol 1969; 33:553-7. 3. Perdue PW, Johnson HW Jr, Stafford PW. Intestinal obstruction complicating pregnancy. Am J Surg 1992; 164:384-8. 4. Harer WB Jr, Harer WB Sr. Volvulus complicating preg- nancy and puerperium. Obstet Gynecol 1958; 12:399- 406. 5. Keating JP, Jackson DS. Sigmoid volvulus in late preg- nancy. J R Army Med Corps 1985; 131:72-4. 6. Lord SA, Boswell WC, Hungerpiller JC. Sigmoid volvu- lus in pregnancy. Am Surg 1996; 62:380-2. 7. Kohn SG, Henry AB, Douglass LH. Volvulus complicat- ing pregnancy. Am J Obstet Gynecol 1944; 48:398-404. 8. De U, De KK. Sigmoid volvulus complicating pregnan- cy. Indian J Med Sci 2005; 59:317-9. 9. Joshi MA, Balsarkar D, Avasare N, Pradhan C, Pereira G, Subramanyan P, et al. Gangrenous sigmoid colon in a pregnant woman. Trop Gastroenterol 1999; 20:141-2. 10. Hofmeyr GJ, Sonnendecker EW. Sigmoid volvulus in advanced pregnancy. Report of 2 cases. S Afr Med J 985; 67:63-4. 11. Fraser JL, Eckert LA. Volvulus complicating pregnancy. Can Med Assoc J 1983; 128:1045 12. Alshawi JS. Recurrent sigmoid volvulus in pregnancy. Report of a case and review of the literature. Dis Colon Rectum 2005; 48:1811-3. 13. Lurie S, Katz Z, Rabinerson D, Simon D. Sigmoid vol- vulus after medical management with subsequent op- erative laparoscopy of unruptured ectopic pregnancy. Gynecol Obstet Invest 1997; 43:204-5. 14. Allen JC. Sigmoid volvulus in pregnancy. J R Army Med Corps 1990; 136:55-6.