D J M Macdonald, ,K Popli*, D Byrne+ K Hanretty#
Department of Orthopaedics, Western Infirmary, Glasgow
*Department of Obstetrics and Gynaecology, Forth Park Hospital, Bonnochy Road, Kircaldy, Fife
+Department of Surgery, Gartnavel General Hospital, Great Western Road, Glasgow
#Department of Obstetrics and Gynaecology, The Queen Mother’s Hospital, Yorkhill NHS Trust, Glasgow
Correspondence to: Mr Duncan J M Macdonald, e-mail: djmmacd@hotmail.com
SMJ 2004 49(4): 159-160
Small bowel obstruction in pregnancy is unusual. It is a difficult diagnosis to make, as vomiting and abdominal distension are commonly associated with pregnancy, and x-rays are avoided if possible. We present a case of small bowel obstruction caused by uterine fibroid degeneration in a 37 year old with a twin pregnancy. Following a period of observation an x-ray was performed which prompted surgical exploration, relief of the obstruction and myomectomy. This case highlights that x-ray is essential if there is a clinical suspicion of small bowel obstruction in pregnancy as delay in diagnosis can be catastrophic. As childbearing is increasingly delayed into later life it is possible that pregnancy complicated by fibroids will be seen more frequently.
Keywords: pregnancy complications, intestinal obstruction, uterine fibroids, myomectomy
A 37-year-old para 1+2 with a twin pregnancy of 17 weeks gestation presented with a 72 hour history of colicky central abdominal pain and vomiting. On examination she appeared distressed and dehydrated. Her pulse was 88 beats/minute, blood pressure was 136/60 mmHg and she was afebrile. On inspection her abdomen appeared distended, there was moderate tenderness in the epigastrium and she had active bowel sounds. The uterus was soft, non-tender and its size corresponded to that of a 22 weeks singleton pregnancy. Two live fetuses were confirmed with an ultrasound scan. She had moderate ketonuria but her full blood count, liver function tests, serum amylase, urea and electrolytes were all within normal limits.
As there was no obvious obstetric cause for her symptoms, a surgical opinion was sought. She was provisionally diagnosed as suffering from gastroenteritis and managed conservatively with intravenous fluids, analgesics, antispasmodics and anti-emetics. Her pain subsided but the abdominal distension and vomiting continued. On the third day a nasogastric tube was passed and a copious volume of bilious fluid was drained. Her general condition deteriorated and the next day a plain abdominal x-ray was performed. This demonstrated significantly dilated loops of small bowel consistent with small bowel obstruction.(Fig. 1) As a result she was taken for a laparotomy by a joint obstetric and general surgical team.
A midline laparotomy was performed which revealed greatly dilated loops of small bowel, three of which were adherent to a large pedunculated subserosal fibroid. This was the site of obstruction and the bowel was freed without injury to its wall. The surface of the fibroid was necrotic. Due to its abnormal appearance and in order to prevent recurrent obstruction a myomectomy was performed. As it was a pedunculated fibroid the removal was not difficult and haemostasis was achieved by oversewing the defect in the uterine wall. There were no other obvious fibroids on inspection and palpation of the uterus. The omentum was laid over the fundus of the uterus before returning the small bowel. 500mls of Adept solution was left in the abdomen before closure. The fibroid measured 5.5cm x 5cm x 4.5cm and histopathological examination showed various patterns of degeneration associated with an acute inflammatory cell infiltrate. There were some foci of haemorrhage and other areas of hyalinisation but no evidence of malignancy. She made slow but steady recovery and was discharged home on the sixth post operative day. Unfortunately seven weeks later she presented with pre-term labour at 25 weeks gestation and delivered twin girls weighing 700g and 740g. The babies were in poor condition at birth and subsequently died.
Small bowel obstruction in pregnancy is unusual. A retrospective review of 150,386 pregnancies, identified nine cases. Eight of these were operated on and the cause identified as adhesions. Three of these cases resulted in fetal death.1 While adhesions are the most common cause of small bowel obstruction, volvulus, intussusception, herniae, appendicitis and carcinoma are also recognised. Small bowel obstruction in pregnancy, may rarely be caused by fibroids and to the authors’ knowledge only one such case has been described in the literature2 and none with a multiple pregnancy.
Once the diagnosis of small bowel obstruction has been made in the pregnant woman, the recommended treatment is surgery regardless of the gestational age or status of the fetus.3 A maternal mortality rate of 6% and fetal mortality rate of 20-26% is reported in such cases.4 The reported incidence of fibroids in pregnancy varies between 0.09% to 3.9%.5 Approximately 10% of women with fibroids will have related complications during pregnancy6. These include pain, bleeding, pre-term premature rupture of membranes, malpresentation, increased caesarean section rate, miscarriage, post partum haemorrhage and post partum endomyometritis.6,7,8 The median age of patients affected by fibroids in one study was 33.4 years8 and it is believed by some authors that the prevalence of pregnancies complicated by fibroids is likely to increase as women delay childbearing until later in life.9,10 Myometomy is conventionally discouraged in pregnancy because of the risk of haemorrhage, miscarriage and preterm labour. However, it can be performed safely if necessary11 and the risk of miscarriage does not seem to be significantly increased when performed in carefully selected patients.12
Non obstetric surgical emergencies can be difficult to recognise in a pregnant woman whose normal physiological state is altered by pregnancy. Clinical suspicion of small bowel obstruction in pregnancy is critical given the potentially serious consequences. If vomiting in pregnancy is persistent and associated with pain then small bowel obstruction should be considered. In this instance plain abdominal x-ray had deliberately been delayed to avoid fetal radiation exposure but it is noteworthy that the result of the x-ray was instrumental in the decision to operate. Since women are delaying child bearing until later in life, pregnancies associated with fibroids will be seen more frequently. An awareness of the complications that may arise is essential to prevent a potentially catastrophic outcome for two, or more, lives.
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