Author(s): Jasbir Kaur Saluja1, Pulkit Kumar Roy2, Vishal Dubey3, Monika Aggarwal4, Rinku Kushwaha5
A 26 year primigravida was referred with the diagnosis of 28 week pregnancy with intestinal obstruction. She complained of distension, pain in abdomen, not passing stool and flatus since 2 days, vomiting since 1 day. No history of previous surgery. On examination, her condition was poor, pulse 120/min., respiration 44/min. and blood pressure 100/60 mmHg. Abdominal inspection revealed gross distension. On palpation, abdomen was tense, guarding and tenderness was present, no fluid thrill or shifting dullness found, bowel sounds absent. Height of uterus was not clearly marked. Vaginal examination showed foetal head deep in pelvis and cervical os closed and posteriorly placed. Per rectal examination revealed an empty rectum. Investigation- HB 8.7 g%, blood group- O negative, WBC 20.95 x 103/UL, urine examination positive for blood cells, pus cells 40-50/hpf and RBC 30-40/hpf. USG whole abdomen showed subacute intestinal obstruction with mild ascites. USG obstetrics showed 28 weeks pregnancy with intrauterine dead foetus. X-ray abdomen standing showed multiple free fluid levels suggestive of intestinal obstruction. Fluid resuscitation and intravenous antibiotics were started, nasogastric tube suctioning had large amount of bilious fluid (approximately 1000 mL). Surgical referral suggested subacute intestinal obstruction.
Patient was taken for exploratory laparotomy. Operative findings- There was 500 mL of foul-smelling peritoneal fluid, which was sent for culture sensitivity and gram staining. Blackish discolouration and non-viability of bowel (gangrenous) extending from jejunum to transverse colon due to mesenteric ischaemia caused by encircling of mesentery at its base by transverse colon, which was acting as a band was seen. Resection of such a long length of bowel was not possible and surgeon took the decision of non-resection of gangrenous bowel. Whole of the gangrenous bowel inserted in the abdomen as it was. Caesarean section was done, baby male 1.3 kg stillborn delivered, uterus and abdomen closed in layers. Postoperatively, given and antibiotics continued, but patient could not survive and died after 11 hrs. of laparotomy.