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We all travel the long and winding road.

A lot of turns will mislead us, but the right sense of direction
will take us where we need to be.

Good afternoon everyone, today, we are presented with the case of a 35-year-old female, G4P3
(3002) pregnancy uterine at 34 2/7 weeks AOG, who initially presented with no bowel movement
which later progressed to severe epigastric pain, with associated vomiting, decrease appetite
and occasional uterine contractions. Given this history, together with the physical examination
result, laboratory results and imaging findings (FLASH PHYSICAL EXAMINATION AND EXAMINATION
RESULTS), we have arrived at the impression of: G4P3 (3002) pregnancy uterine, 34 2/7 weeks Age
of Gestation in Threatened Preterm Labor; Complete bowel Obstruction probably due to
gastrointestinal vs. OB-gynecologic pathologies; Cholelithiasis.

According to WHO and an article by Bansal, threatened Preterm Labor is defined as the presence
of regular uterine contractions documented in the absence of cervical changes and relating this
to the patients pregnancy, the internal examination result revealing closed and uneffaced cervix
in a background of occasional uterine contractions is consistent with the said definition.

At this juncture, we are left with the question: Is the patients threatened preterm labor spontaneous
or secondary to other causes?

With this question in mind, our investigation will center on the patients abdominal pain, vomiting
and absence of flatus and bowel movement in a course of 7 days with bowel ileus, fecal stasis
and paucity of rectal gas as seen on flat plate. According to Merk, this cluster of findings would
normally indicate MECHANICAL BOWEL OBSTRUCTION, which is defined as the arrest of passage
of contents through the intestine due to bowel blocking pathologies. Furthermore, mechanical
obstruction can be divided according to degree of obstruction being partial or complete and
location of obstruction being the small bowel or large bowel.

Regarding the degree of obstruction, partial bowel obstruction presents with obstipation and
passage of some gas or stool. On the other hand, complete bowel obstruction is characterized by
failure to pass stool or flatus with an empty rectal vault which was noted in our patient. (Insert
Sabiston cover book in the slide)

Differentiating between the level of obstruction, Schwartz and Sabiston noted that Small bowel
Obstruction presents with colicky abdominal pain, nausea and vomiting and OBSTIPATION while
large bowel obstruction presents with crampy abdominal pain, nausea and vomiting and
ABDOMINAL DISTENTION.

However, Williams noted that these differentiating features between Small and Large Bowel
Obstruction are commonly obscured in pregnant patients due to the large uterus that displaces
abdominal organs from their normal location, hence, atypical findings like pain in the epigastric
region are commonly seen as in the case of the patient. Also, according to Saale, et al., the
radiographic triad of Small Bowel Obstruction including dilated small bowel loops, air-fluid levels
on upright films and paucity of air in the colon have a sensitivity of 75% only and have a decreased
specificity in pregnant women. Hence, the location of the obstruction in our patient cannot be
totally determined.

In the journals authored by Chang et al., Johri et al., and Siwatch et al, pregnancy has been
proven to be a significant factor in determining the pathologies involved in bowel obstruction.
These researchers identified the following five gastrointestinal causes of intestinal obstruction as
most common causes during pregnancy: (Flash a: adhesions, b: volvulus, c. Appendicitis, d.
intussusception, e: carcinoma).
First- Intraperitoneal Adhesions: with a 55% prevalence rate among causes of intestinal obstruction
in pregnant women, this commonly result from previous abdominal surgeries. In the study of El
Marsy et al., it was found out that intraperitoneal adhesions form in 55% to 100% of women who
underwent LSCS and they were asymptomatic after months, years or even lifetime post-
operatively. However, it was found out that women with post-operative adhesions who became
pregnant have greater risk of intestinal obstruction as pregnancy progress due to the inability of
the bowels to adapt with the distortive effects of pregnancy. In our patient, LSCS was done on her
first pregnancy and symptoms of intestinal obstruction only occurred during her 3rd trimester of her
current pregnancy, hence this diagnosis is highly likely.

Second-Volvulus: this accounts to 25% of bowel obstruction in pregnant women. According to


Williams, pregnancy is an independent risk factor in the formation of volvulus, most common in
the sigmoid area and rarely seen in the cecum and small bowels. Sigmoid volvulus in pregnancy
occurs due to the displacement of the mobile sigmoid loop by an elongating uterus causing the
twisting of the sigmoid around its mesocolon. Furthermore, it was noted that third trimester of
pregnancy, multiparity and age group of 15-35 years, which are all present in the patient,
increases the chance for a sigmoid volvulus by 75%, hence, making this diagnosis highly likely.

Third: Appendicitis- is a common cause of acute abdomen in pregnancy which usually presents
with RLQ pain, however, due to the cephalad migration of the appendix following uterine
distention, pain may present in the flank or RUQ. Bowel irregularity can occur in cases of extrinsic
bowel compression should a ruptured appendix form phlegmon. However, with an Alvarados
score of 4/10 (Show slide: Migratory pain= 0, Anorexia= 1; Nausea/Vomiting= 1; Tenderness= 0,
Rebound= 0, Fever= 0, Leukocytosis= 2, Shift to the left= 0) appendicitis is less likely.

Fourth: Intussusception- while this presents with the similar signs and symptoms of obstruction, this
only accounts to 1-5% of bowel obstruction in pregnant women which makes it a rare clinical
impression. Furthermore, Penney et al. stated that ultrasonographic finding of single or double
anechoic rings allows for better consideration of intussusception. However, with the absence of
this ultrasound finding, this diagnosis is less likely.

Last: Gastrointestinal Neoplasms- can also cause intestinal obstruction by means of intramural
growth and among of these neoplasms, colorectal carcinoma is the most common with a
prevalence of 25%. According to Vanagunas, colorectal carcinomas have the tendency to grow
further during pregnancy due to the increased levels of progesterone which is a stimulant to
carcinoma growth causing luminal obstruction. However, carcinomas of the colon usually present
an indolent course and among its symptomatology, weight loss and rectal bleeding are expected
findings which were absent in the patient. Furthermore, colorectal tumors seldom complicate
pregnancy because they are uncommon before the age 40, making this diagnosis less likely.

Now that we have examined gastrointestinal causes of mechanical obstruction, gynecologic


causes should also be examined since extrinsic compression of the bowels may result to the same
condition. Among gynecologic causes of bowel obstruction, 50% accounts to ovarian carcinoma
manifesting most of the time as small bowel obstruction. However, according to Behtash et al.,
the incidence of ovarian carcinoma leading to intestinal obstruction in pregnancy is extremely
rare with an incidence of 1 in 25,000 pregnancies, hence, making gynecologic causes unlikely.

Finally, focusing our investigation on obstetric aspect of the patient, the possibility of an intestinal
obstruction during pregnancy becomes more likely as term approaches. This is due to the rotation
of the gravid uterus which favors extrinsic intestinal compression and may even produce
complete intestinal obstruction. According to Vanagunas, the incidence of intestinal obstruction
by a gravid uterus is only 1 in 3000 pregnancies, but, this markedly increases when associated with
intraperitoneal adhesions and volvulus. Hence, bowel obstruction due to a gravid uterus per se is
less likely in our patient, but it becomes more likely due to a possible consideration of adhesions
and/or volvulus in the patient.

Now that we have explored the gastrointestinal, gynecologic and obstetric considerations of our
patients conditions, we therefore arrive at our final diagnosis:
G4P3 (3002) pregnancy uterine, 34 2/7 weeks Age of Gestation, in Threatened Preterm Labor;
Complete Bowel Obstruction secondary to Gravid Uterus, cannot totally rule out Intraperitoneal
adhesions, s/p Primary LSCS (2011), cannot totally rule out Sigmoid Volvulus;
Cholelithiasis

In the case presented, it has been shown that a gravid uterus, may on its own or in relationship to
other gastrointestinal pathologies, lead to intestinal obstruction. However, we havent completely
solved the puzzle yet for it must be asked: Is the patients threatened preterm labor spontaneous
or secondary to other causes?

According to the CDC, maternal stress is a considered risk factor for a threatened preterm labor
and according to Chang et al. Intestinal Obstruction which is a source of pain, nausea and
vomiting is a significant source of maternal stress that may result to preterm labor. According to
Schuster, maternal stress causes increase in cortisol production which triggers production of
Prostaglandin E2 which is a hormone that induces uterine contractility. Hence, it can be said that
patients threatened preterm labor may be secondary to patients intestinal obstruction.