Sigmoid and Cecal Volvulus following Cesarean Twin Delivery

Background: Bowel obstruction in pregnancy occurs in about 1 in 10,000 pregnant women. The most common causes include adhesions (60%), volvulus (25%), intussusception (5%), carcinomas (3.5%) and hernia (1.5%). There are theories regarding pregnancy and how its associated physiologic changes can slightly increase the risk of intestinal volvulus. These include progesterone-induced bowel relaxation, decreased peristalsis, and fecal retention. Additionally, an abnormally mobile colon secondary to the enlarged uterus is believed to be the mechanism by which the colon is pushed out of the pelvis and is more likely to rotate around its mesentery. Intestinal volvulus is a medical emergency and complications include bowel perforation, peritonitis, and sepsis. Given such life-threatening complications, it is imperative to identify volvulus early and treat it accordingly. Purpose: To report a rare case of sigmoid and cecal volvulus following routine cesarean delivery. Method: Case Report Results: A 40-year-old G9P3053 female at 33 weeks and 5 days gestation dichorionic/diamniotic twin gestation with past medical history of hypertension, recurrent pregnancy loss and isthmocele repair presented for chronic hypertension with superimposed preeclampsia with severe features. Initial blood pressure on arrival was 164/94 mmHg which rechecked to 159/95 mmHg. Initial review of systems was significant for bilateral lower extremity edema and recurrent headache. She was treated with magnesium sulfate and a course of betamethasone and remained hospitalized for observation. Over the next two days, her symptoms progressed to a persistent headache minimally responsive to analgesics and persistent mild range blood pressure readings, so the decision was made to proceed to the operating room (OR) for a repeat cesarean delivery. The procedure was complicated by post-partum hemorrhage with an estimated blood loss of 1.5L but was otherwise uncomplicated. Blood products were provided, and the patient’s post-operative hemoglobin and hematocrit were monitored and found to be stable. By post-operative day 2, the patient had developed abdominal distention and reported no flatus or bowel movement since the day prior. By post-operative day 3, her abdominal distention had worsened, and the patient began having notable abdominal pain, prompting an abdominal X-ray. This revealed dilated gas and stool-filled loops of small and large bowel persistent with right-sided bowel distended up to 14 cm. Additionally, the bowel lumen was dilated secondary to sigmoid volvulus at 28cm from the anal verge. General surgery was consulted, and the patient immediately underwent endoscopic decompression of her sigmoid volvulus. The patient reported temporary improvement in her abdominal pain, but the next day remained significantly distended with return of her generalized abdominal pain. A repeat X-ray was ordered, and findings were significant for dilation of the cecum with wall thickening and edema and displaced to the midline anteriorly. These findings were concerning for cecal volvulus, which was confirmed by CT of the abdomen and pelvis. The patient was then taken to the OR for an exploratory laparotomy and ultimately underwent a partial colectomy with ileocolonic anastomosis. She was then transferred to the surgical trauma ICU for post-operative monitoring. Repeat KUB X-ray was negative for any other acute intra-abdominal abnormality, and the patient was transferred to the floor the following day with resolution of her abdominal discomfort and distension. The remainder of her hospitalization was complicated by pulmonary emboli of the right posterior basal segment and left posterior basal arteries as well as bibasilar atelectasis, but she did not have any additional gastrointestinal complications. She was started on Enoxaparin for management of her pulmonary emboli, she recovered well, and was discharged home on post-operative day 3 from her recent exploratory laparotomy. Conclusion: While intestinal volvulus is a known potential complication of intra-abdominal surgery, it is a rare complication of obstetrical procedures in the absence of prior laparotomy. Although it is unknown what factors contributed to the development of volvulus in our patient, we conclude that patients experiencing abdominal distention, constipation and obstipation in the immediate post-operative period would benefit significantly from abdominal X-ray to assess for possible bowel obstruction secondary to volvulus and treated with operative management should this diagnosis be confirmed.