Keywords : intestinal obstruction ● pregnancy ● postpartum
Surgical complications are rarely suspected in pregnancy. Delay in the diagnosis of intestinal obstruction may contribute significantly to maternal mortality, (around 20%) 1,3. One such case that posed a clinical dilemma is reported.
A 32-year-old nulliparous second gravida with gestational diabetes was admitted at term on 13th November 2004 for cesarean delivery. The night before scheduled cesarean, she had an episode of excessive sweating along with maternal bradycardia and spontaneous fetal heart decelerations. The episode was managed as hypoglycemia. As scheduled, cesarean section was done on 15th November, 2004 and a female baby weighing 3.2 kg was delivered with apgar of 9 at 1 minute of 10 at 5 minutes.
The patient complained of generalized intense pain in the abdomen 8 hours after the cesarean and was managed with analgesics. The pain persisted and by 18 hours post operation abdominal distension was noticeable and bowel sounds were absent. A palpable tender mass was noted in right hypochondrium. X- ray and ultrasonography of the abdomen showed grossly distended small bowel loops with air fluid levels (Figure 1). Conservative management for intestinal obstruction failed to improve the condition. Exploratory laparotomy on the 4th postoperative day i.e. 18th November, 2004 revealed gangrenous terminal ileum and the adhesive band that caused the obstruction (Figure 2). Release of the fibrous band with resection of gangrenous ileal segment and end to end anastomosis was done.
The patient made gradual recovery following complicated postoperative period requiring intensive multidisciplinary care with ventilator support. She was discharged in good condition on 3rd December 2004.
On enquiry it was found that the patient had an appendicectomy two years earlier, following which she had abdominal pain on and off .
Adhesions due to past surgery, eg. appendicectomy 
B) Erect abdominal X-ray showing multiple air - fluid levels in dilated small bowel loops.
are the commonest cause for intestinal obstruction in pregnancy. Transition from the first to the second trimester when uterus and adnexa become abdominal, entering of the head in the pelvis near term and soon after delivery are periods when obstruction can manifest 2,3. The patient reported here had an appendicectomy two years earlier. She had evidence of intestinal disturbances after appendicectomy in the form of on and off pain in the abdomen, diarrhea followed by constipation that she had near term and the episode of sweating with transient bradycardia the day before cesarean delivery. The window formed by the fibrous band of adhesion letting in loops of intestine may have been the cause of on and off pain in abdomen as well as the cause of the bowel disturbances she had near term. Probably the episode of sweating with transient bradycardia could have been due to a significant obstruction. The bowel distension due to postcesarean ileus would have caused strangulation of the obstructed loop of the intestine.
The pain she experienced was thought to be postoperative pain. Abdominal distension with a palpable mass and dilated bowel loops on x-ray was attributed to be postoperative ileus. It was her deteriorating clinical condition that led to a laparotomy being performed.
Intestinal obstruction should be thought of whenever a pregnant woman with past abdominal surgery presents with bowel disturbances and abdominal distension. Prompt diagnosis and active intervention will minimize the morbidity.
