1. CASE PRESENTATION ON PATIENT
MANAGED FOR 3RD TM PREGNANCY +
IUFD + ACUTE ABDOMEN 2o TO SBO 2o
TO SBV + RH NEGATIVE MOTHER
By Dr. Masresha (R1)
Moderator: Dr.(R4)
2. OUTLINE
• Case summary
• Discussion
• Scientific discussion
• Comment
• Take home message
• Reference
2
5. Evaluation by surgical side resident at
EOPD on 22/04/15
• This is G5P2(All alive)mother
• Amenorrhea of 8 months
• Presented with crampy abdominal pain, vomiting of
bilious matter, failure to pass feaces and flatus and
abdominal distension of 36hr duration
5
6. Continued …
• Was feeling fetal mov’t a day back
• Headache of one day duration
• P/E
• GA: ASL
• V/S: BP. 130/90 PR. 108 RR. 20 To. 36.7
• HEENT: Dry toungue
• Chest: Clear and good air entry
6
7. Continued …
• Abd: distended abdomen which moves with
respiratiom
• 28weeks sized gravid uterus
• Hyperactive bowel sound
DRE: scanty stool in the rectum
• PV: 2cm opened cervix & Engaged well
7
8. Ass’t: AA 2o to SOB 2o to SBV + 3rd TM pregnancy +
IUFD + Preeclampsia
• Plan: keep NPO & Resuscitate with crystalloid
• Insert NG tube & catheterize
• Ceftriaxone 1gm IV & metronidazole 500mg IV
• Prepare for emergency laparotomy
• Communicate GYNOBS side
• To consult senior
8
10. Gynobs side resident evaluation note
at on 22/04/15
• Gravida 5 para 4 (all alive, all VD) mother
• Amanorrhic for 8 months
• Has no Anc follow up
• Referred from Dimtu primary hospital with the
diagnosis of “Acute abdomen 2o SBO + Term
pregnancy”
• No pushing down pain or passage of liquor
10
11. Continued …
• P/E
• GA: acute sick looking
• V/S: BP: PR: 120 RR: 26 to:36.4
• HEENT: pink conjunctiva and NISC
• LGS: no SLAP
• Chest: Clear and resonant
• CVS: S1 and S2 well heard
• ABD: grossly distended abdomen
tenderness all over the abdomen
No sign of fluid collection
11
U/S:
• SIUP, FHB: -ve
• Fundal placenta
• FL: 34wk
• No GCA seen
3rd TM Px + IUFD
12. Continued …
• GUS: Cx admit one finger, Uneffeced
• INT/MSS: NO edema
• CNS: COTPP
• ASS’T: 3rd TM Px+IUFD+ Acute abdomen 2o SBO
• Plan: Do plain Abd. X ray
- recommunicate after mgt of her surgical
complication
12
13. Operation note
• After written informed consent patient taken to OR
and on supine position and under GA with ETT in
place
• Abdomen is prepared, draped & interred through
vertical midline incision
Finding
• 1500ml hemorragic fluid with general peritoneum
• Gravida uterus
• ~270o anticlockwise volvulated viable small
bowel(the whole SBO bowel exceptthe 1st 100cm of
jejunum is involved within the volvulus)
• The patency checked
13
14. Continued …
• Done
• Hemorrhagic fluid sucked out
• Volvulated bowel segment derotated
• Patency checked and down milky done
• Abdomen lavaged with warm saline
• Hemostasis secured and guage count correct reported
• Fascia closed by interrupted NO. 2 round vicryl
• Skin closed and dressed with sterile guage
• Patient extubated and transferred to PACU
• N.B. her BP is persistently high through out intar-op
14
15. Continued …
15
Post op plan:
• Keep NPO
• MF
• Cefriaxone 1gm IV BID
• Metronizole 500mg IV
TID
• Tramadol 50mg IV TID
• Diclofenac 75mg IV BID
• Follow V/S, Abd. condition,
catheter and NG-tube
output
• Repeat CBC after 6hr and
coagulation profile after
• Recommunicate GYNOBS for
follow up
• Wound care daily
16. Continued …
• Post op plan:
• Keep NPO
• Maintenance fluid
• Cefrtiaxone 1gm IV BID
• Metronizole 500mg IV
TID
• Tramadol 50mg IV TID
• Diclofenac 75mg IV BID
• Follow V/S, Abd. condition,
catheter and NG-tube output
• Repeat CBC after 6hr and
coagulation profile after
• Recommunicate GYNOBS for
follow up
• Wound care daily
16
17. Senior resident evaluation note at
LW on 25/4/15
• G5P4 (all alive, VD) mother
• Amenorrhic for the past 8 ½ months
• No ANC follow up
• On her 3rd POD after laparotomy and derotation +
dawn ward milking done for SBO
• Diagnosed to have IUFD preoperatively
• Transferred to labor ward with complaint of
passage of liquor of 8hr and pushing down pain of
4hr duration
• She didn’t pass feaces and flatus
17
18. Continued …
• P/E
• GA: In labor pain
• V/S: BP: 128/80 PR. 82 RR. 20 To. 36.7
• Pink conjuctive
• No LAP
• Clear and resonant chest
• S1 and S2 well heard. No murmur and gallop
• Abd. 34wk sized gravid uterus
• longitudinal lie and cephalic presentation
• FHB. –ve
• Ux contraction: 2/10/30-35
• clean sutured midline surgical scar
18
19. Continued …
• U/S: SIUP
FHB –ve
cephalic
FL: 35+2 wks
placenta fundal with CT 4.8cm
No sign of fluid collection
IUFD + 3rd TM Px
No CVAT
Cx. 2cm, M-R-C, 70% effaced and station: high
• ASS’T: 3rd POD + 3rd TM Px + IUFD + Prolonged ROM +
Rh negeative mother
19
20. Continued …
• Plan: Admit to LW
start ceftriaxone 1gm IV BID until delivery
Follow labor progress closely
Recommunicate surgical side after delivery
Consult senior
Continue maintenance fluid
20
21. Augmentation decision note
• Hx and Px revaised
• Admitted to labor ward 8hr back with diagnosis of Th
same + LFSOL
• ON ceftriaxone 1gm IV BID
• P/E
• GA: ASL in labor pain
• V/S: BP. 125/80 PR. 84RR. 22 To.36.6
• ABD. 34wk sized gravid uterus
longitudinal lie and cephalic presentation
FHB –ve; Ux Contraction: 2/10/30-35
21
22. Continued …
• Cx: 3cm dilated and 80% effaced, station high
M-R-C
ASS’T; The same + Prolonged LFOSL
Plan: augment with oxytocin per protocol
Follow FMC closely
22
23. Delivery Summery
• P5 (all alive)
• Aadmitted to LW 9hr back with the diagnosis of 3rd POD
+ 3rd TMPx + IUFD + LFSOL + Prolonged ROM + RH –ve
mother
• Augmented for 3hr with indication of prolonged LFOS
• 5minute back diagnosed with SSOL and transferred to
second stage coach then encuared to push
• After 2 push she delivered grade III macerated female
neonate
• 3rd stage of labor managed actively with Pitocin 10iu IM
placenta delivered with CCT
• Currently she has no bleeding
23
24. Continued …
• P’E
• V/S: BP. 100/70 PR. 94 RR.22 To. 36.6
• ABD. Vertical clean surgical wound
uterus 18wks sized well contracted
• ASS’T: Immediate post partum day + 4th POD after derotation
dorm ward milking done fpr SOB
Plan: advice on danger sign
Give breast care and Psychological support
tramadol 50mg IV TID
Diclofenac 75mg IV BID
Follow FMC closely
recommunicate surgical side
24
25. Surgical side follow up chartfollow up
chart
25
Time BP PR RR TEMP UOP NGT UOP Abd. condition
22-4-
15
7:00pm 118/80 112 26 36.9 Soft
Distended
No tenderness
8:00pm 130/85 104 24 36.6 >>
12:00AM 140/90 100 28 36.7 300ml 200 >>
5:00AM 150/90 96 26 36.6
23-4-
15
7:00AM 131/80 94 28 36.4
11:00AM 120/93 92 26 36.6 800ml 250
5:00PM 103/60 88 24 36.2
24-4-
15
7:30 - 100 26 37.1 300ml/8h
r
3:00 - 92 28 ATT 300ml/8h
r
9:00AM 110/60 100 28 37.1 50ml/2hr
26. LFSOL follow up
Date Time BP PR RR To Cx C FHB Cx Eff. Mem. Remark
24/4/15
11:00Am 128/80 82 26 36.7 2/10/30-
35”
-ve 2cm 70% R-c Ceftriaxon
e 1gm IV
given
11:30 - 2/10/30-35
12:00pm 89 24 2/10/30-35
12:30pm 86 24 2/10/30-35
1:00pm 80 24 2/10/30-35
1:30pm - 2/10/30-35
2:00pm 86 24 2/10/30-35
2:30pm 84 22 2/10/30-35
3:00pm 84 24 2/10/30-35 3cm 70% R-c
3:30pm - 2/10/30-35
4:00pm - 2/10/30-35
4:30pm 86 24 2/10/30-35
5:00pm 88 24 2/10/30-35
5:30pm 84 24 2/10/30-35
6:00pm 84 24 2/10/30-35 26
27. Augmentation follow up chart
27
Date Time BP PR RR To Cx C FHB Cx Eff. Mm pito
cin
pha drp
24/4/15
7:00PM 106/5
8
2/10/30-
35”
-ve 2cm 70% R-c 6IU I 20
7:20PM 2/10/30-35 40
7:40PM 3/10/30-35 60
8:00PM 110/60 20 3/10/30-35 80
8:20PM 110/68 92 20 3/10/30-35 II 40
8:40PM 110/68 90 20 3/10/30-35 60
9:00PM 88 3/10/30-35 80
9:300PM 3/10/30-35
30. Acute abdomen in pregnancy
• Pregnancy complicates the diagnosis and differential
diagnosis of abdominal/pelvic pain due to:
• Symptoms of abdominal pain, nausea, and vomiting
are often attributed to the underlying pregnancy,
• Pregnancy can alter the presentation of some
disease
• Fear of exposure of a fetus to radiation or
unnecessary procedures
30
31. DDX of AA in pregnancy
Non Gynecologic
• Acute appendicitis
• Acute cholecystitis
• Acute pancreatitis
• Bowel obstruction or
perforation
• Diverticulitis
• Abdominal trauma & etc
31
Obstetrical/Gynecologic
• Adnexal mass torsion
• Rupture of ovarian cyst
• TOA
• Ectopic pregnancy
• Uterine rupture
• Degenerated myoma
• Placental abruption
• PE with it’s complication & etc
32. Intestinal obstruction in pregnancy
The incidence is not increased during pregnancy
Small bowel is involved in approximately 80% of
cases
Can be
Functional/mechanical
Complete/ partial
Generally is more difficult to diagnose
Carries significant maternal & fetal mortality
32
34. Bowel volvulus in pregnancy
The incidence has been described as 1/1,500-
66,000 deliveries
More common in prengnanct women than
nonpregnant
34
35. Sign and smptoms
Continuous or colicky abdominal pain (98%)
Nausea and vomiting (80%)
Abdominal tenderness (70%)
Abnormal bowel sounds (55%)
Constipation and diarrhea are uncommon
35
36. Imaging is essential for early and precise
diagnosis
Plain abdominal radiographs
CT
MRI
Colonoscopy
36
37. Mgt
Mortality rates can be excessive b/c of difficult &
thus delayed diagnosis, reluctance to operate
during pregnancy
Management of IO in pregnancy is similar to
nonpregnancy
Nasogastric aspiration with aggressive iv fluids
37
38. Failure of conservative treatment & demonstration
of complete IO are indications for early surgery
Perinatal death from hypoxia has been reported
Surgery should be performed via midline incision
38
39. Nonobstetric surgery in pregnant
• 1 to 2 percent of pregnant women will undergo a
nonobstetrical surgical procedure
• The need for nonobstetric surgery can arise at any
point in gestation
• Requires a multidisciplinary approach
39
40. Common non-obstetric surgeries
• Appendectomy
• Cholecystectomy
• Adnexal surgery (for torsion or masses)
• Trauma repair
• Small-bowel obstruction surgery
• Breast surgery
40
42. Special management considerations
1. Timing of surgery
• Emergency surgery should be performed
regardless of the trimester
• Surgery that is urgently required should be done
during the early second trimester
2. Glucocorticoid administration
• If GA<34weeks and viable
3. Anesthesia choice
• Spinal anesthesia is preferred
42
43. 4. Intubation precautions
5. Patient positioning
• 30o tilt to left to increase venous return
6. Intraoperative fetal monitoring
7. Venous thromboembolism prophylaxis
43
44. CS during nonobstetric surgery
• Indication for intraoperation CS
• Intraoperation NRFHRP
• If the gravid uterus obscure visibility of
operation site
44
45. COMMENTS
Strength
• Early diagnosis and
mgt
45
Weakness
• PE is not investigated
•
• VDRL and HBSAg ???
• Diclofenac IV?
• FeSo4 not provided
•
46. Take home message
• We have to suspect intestinal obstruction in all
pregnant women with abdominal pain and vomiting
as physical examination may be obscured by gravis
uterus
• Early diagnosis and intervention is critical as delay in
intervention is associated with poor maternal and
fetal outcome
46
rare in nonpregnant patients (<1%) can be seen in up to 9% SBOs and 25% of colonic obstructions in the pregnant patients
Taken together, it would seem reasonable to reassure pregnant patients faced with the need for surgery in pregnancy that the overall rate of mortality and morbidity is similar to the nonpregnant state and that adverse perinatal outcome is relatively low.
Urgent and emergency surgeries should not be delayed because the patient is pregnant, while elective procedures can wait until after delivery
