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Volvulus of cecum as a post-partum complication
VOLVULUS
OF CECUM
LIEUTENANT
AS A POBT-PAB!!!UM
CO~~CATION
COMMANDER DEAN E. SHELDON,* MC-V(S) (From. the T7. S. Naval Hospital, P~i~~e~~~~, Pa.)
, USNR
ITTLE
can be found in American medical literature associating of the cecum with pregnancy. The enlarging gravid uterus has been known to precipitate volvulus. An article appearing in the British Mtdicai! Journal for October 25, 1941, p. 577, presents the case history of a patient succumbing to volvulus of the cecum following a The diagdifficult high forceps delivery in a 3%year-old primigravida. nosis was made at autopsy. The author called attention to the fact that surgeons are reluctant to resort to surgical intervention during the puerperium and that abdominal complications are accordingly neglected. He further stated that pelvic peritonitis, retroperitoneal hemorrhage, paralytic ileus, and abdominal castrophes such as volvulus, all may produce abdominal distention and be found as postpartum complications. A case of volvulus of the cecum, as an unusual post-partum complication, was currently observed in the family outpatient department of the U. S. Naval Hospital, Philadelphia. A primigravida, 33 years of age, presented herself in the dependent clinic on March 31, 1943. Her last menstrual period had occurred on October 25, 1942, the estimated date of confinement being August 2, 1943. Family history was noncontributory. The patient had typhoid fever at the age of 18 years. Gastrointestinal history revealed the presence of an obstinate constipation which had largely subsided after the second month of pregnancy. The prenatal course preceding her first visit to the dispensary had been normal. The patient was a small, well-developed and well-nourished white woman of German extraction. Her usual weight had been. 112 pounds. There was a weight gain of ten pounds the first five months of pregThe abdomen was nancy. General physical examination was negative. enlarged to the size consistent with a five months’ pregnancy and the uterus was in the midline. Pelvic measurements were considered to be adequate for a vaginal delivery. The prenatal course was uneventful until the eighth month when the patient developed a mild pitting edema of the extremities. The laboratory examinations were consistently normal.. The weight gain eontinued to 134 pounds, or a total weight gain of 22 pounds. The patient was admitted to the family out-patient obstetrical iloor at St. Agnes Hospital at 6:30 A.M. on July 21, 1943. Pains had begun three hours before and the head was deeply engaged in the left occiput posterior position. The head rotated spontaneously to an anterior position and a low forceps delivery was completed at 10 A.M. The placenta was expressed intact with an estimated blood loss of 300 C.C. Reaction to delivery and anesthesia was normal and the patient was comfortable until 9 :30 P.M. the day of delivery. At this time there was upper and lower abdominal distention which was relieved by rect,al tube
L
volvul~s
*The opinions or assertions contained herein are not to be construed as ofRcia1 or reflecting the Navy Service at large.
268
are the private ones of the writer the views of the Navy Department
and or
SHELDON
:
VOLVULUS
OF
CECUM
AS
COMPLICATION
269
and the removal of 500 C.C. of urine by catheter. The patient rested comfortably the remainder of the night. The morning of the first postpartum day the patient again complained of upper abdominal pain which was again relieved by rectal tube and the administration of one ampule of prostigmine. Temperature, pulse, and respiration were normal and the patient was still unable to void. By 11 :OO P.M. of this day the patient again complained of severe upper abdominal pain. There was a soft, upper abdominal distention and the abdomen was not tender. Hot abdominal stupes were applied and a soda bicarbonate enema administered. This resulted in the passage of stool and flatus and relief of pain. On the morning of the second post-partum day t,here was a moderate upper abdominal distention, but the patient was retaining fluids by mouth, expelling flatus, and temperature and pulse were normal. She was still unable to void. One ounce of castor oil was administered by mouth and four hours later there was a copious bowel movement with a reduction in the distention, and an almost complete relief of pain. One hour later, and for the first time since delivery, the patient vomited some undigested food. By 9:30 P.M. the distention had recurred and a consultation was requested from the surgical service of the U. 8. Naval Hospital. Paralytic ileus and partial mechanical obstruction were considered to be tentative diagnoses. The patient was still afebrile ; pulse rate of 80. Wangensteen suction was instituted and three units of plasma administered. A flat plate of the abdomen taken on the morning of the third postpartum day was not entirely satisfactory because of gaseous distention, but it revealed a large bowel distention with no definite point of obstruction. Examination of the abdomen showed some visible peristalsis. Five hundred cc. of titrated blood were administered. Following this the patient had a chill and temperature elevation to 103.5O F. Temperature returned to normal four hours later and the supposition was that the chill and fever represented a transfusion reaction. Distention remained moderate throughout the day. On the morning of the fourth post-partum day, the distention was definitely accentuated, the abdomen was tender, no peristalsis could be discerned by auscultation and the patient’s condition was obviously more critical. Temperature was mildly elevated and the pulse rate was increased. At 2 :OO P.M. on the fourth postpartum day, operation was done under continuous spinal anesthesia. The abdomen was entered through a small left reetus incision revealing a hyperemic peritoneum and an increase in intraperitoneal fluid. A huge sausage-shaped mass could be felt extending obliquely upward and to the left across the abdomen. As the incision was enlarged, a volvulus of the eecum and lower portion of the ascending colon spontaneously delivered itself. The mesocolon was edematous and definitely elongated and the bowel had rotated counterclockwise, allowing the cecum to occupy a position beneath the left lobe of the liver. The bowel was dusky, there were some breaks in the serosa, but no evidence of devitalization. Reduction of the volvulus was easily accomplished and cecostomy was performed, the cecostomy tube being carried out through a stab wound in the right lower quadrant. The abdomen was closed without drainage after the introduction of five grams of sulf athiazole crystals. Three units of plasma were given and the immediate postoperative condition was excellent.
270
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
Wangensteen drainage was continued. Intravenous sodium sulfathiazole was administered at eight-hour intervals, and plasma, &rated blood, and intravenous glucose sohnion were given. The patient was irrational on the first and second postoperative days. There was a mild jaundice which was thought to be hemolytic and associated with the transfusions. Maximum temperature elevation reached 103.4O F. The Wangensteen tube was removed on the third postoperative day, and the colostomy tube and all sutures were removed by the fourteenth postoperative day. The patient was discharged from the hospital on the twentieth postoperative, or the twenty-fourth post-partum day. Her bowel habits had been normal for one week at the time of her discharge. This case constitutes an unusual complication following a normal delivery. We feel that delivery with the sudden emptying of the uterus was a contributory factor. A partial obstruction probably existed from the time shortly following delivery, becoming complete on the evening of the third post-partum day. It is conceivable that an exact diagnosis could have been arrived at preoperatively, and surgical intervention instituted at an earlier date.
OF CECUM
LIEUTENANT
AS A POBT-PAB!!!UM
CO~~CATION
COMMANDER DEAN E. SHELDON,* MC-V(S) (From. the T7. S. Naval Hospital, P~i~~e~~~~, Pa.)
, USNR
ITTLE
can be found in American medical literature associating of the cecum with pregnancy. The enlarging gravid uterus has been known to precipitate volvulus. An article appearing in the British Mtdicai! Journal for October 25, 1941, p. 577, presents the case history of a patient succumbing to volvulus of the cecum following a The diagdifficult high forceps delivery in a 3%year-old primigravida. nosis was made at autopsy. The author called attention to the fact that surgeons are reluctant to resort to surgical intervention during the puerperium and that abdominal complications are accordingly neglected. He further stated that pelvic peritonitis, retroperitoneal hemorrhage, paralytic ileus, and abdominal castrophes such as volvulus, all may produce abdominal distention and be found as postpartum complications. A case of volvulus of the cecum, as an unusual post-partum complication, was currently observed in the family outpatient department of the U. S. Naval Hospital, Philadelphia. A primigravida, 33 years of age, presented herself in the dependent clinic on March 31, 1943. Her last menstrual period had occurred on October 25, 1942, the estimated date of confinement being August 2, 1943. Family history was noncontributory. The patient had typhoid fever at the age of 18 years. Gastrointestinal history revealed the presence of an obstinate constipation which had largely subsided after the second month of pregnancy. The prenatal course preceding her first visit to the dispensary had been normal. The patient was a small, well-developed and well-nourished white woman of German extraction. Her usual weight had been. 112 pounds. There was a weight gain of ten pounds the first five months of pregThe abdomen was nancy. General physical examination was negative. enlarged to the size consistent with a five months’ pregnancy and the uterus was in the midline. Pelvic measurements were considered to be adequate for a vaginal delivery. The prenatal course was uneventful until the eighth month when the patient developed a mild pitting edema of the extremities. The laboratory examinations were consistently normal.. The weight gain eontinued to 134 pounds, or a total weight gain of 22 pounds. The patient was admitted to the family out-patient obstetrical iloor at St. Agnes Hospital at 6:30 A.M. on July 21, 1943. Pains had begun three hours before and the head was deeply engaged in the left occiput posterior position. The head rotated spontaneously to an anterior position and a low forceps delivery was completed at 10 A.M. The placenta was expressed intact with an estimated blood loss of 300 C.C. Reaction to delivery and anesthesia was normal and the patient was comfortable until 9 :30 P.M. the day of delivery. At this time there was upper and lower abdominal distention which was relieved by rect,al tube
L
volvul~s
*The opinions or assertions contained herein are not to be construed as ofRcia1 or reflecting the Navy Service at large.
268
are the private ones of the writer the views of the Navy Department
and or
SHELDON
:
VOLVULUS
OF
CECUM
AS
COMPLICATION
269
and the removal of 500 C.C. of urine by catheter. The patient rested comfortably the remainder of the night. The morning of the first postpartum day the patient again complained of upper abdominal pain which was again relieved by rectal tube and the administration of one ampule of prostigmine. Temperature, pulse, and respiration were normal and the patient was still unable to void. By 11 :OO P.M. of this day the patient again complained of severe upper abdominal pain. There was a soft, upper abdominal distention and the abdomen was not tender. Hot abdominal stupes were applied and a soda bicarbonate enema administered. This resulted in the passage of stool and flatus and relief of pain. On the morning of the second post-partum day t,here was a moderate upper abdominal distention, but the patient was retaining fluids by mouth, expelling flatus, and temperature and pulse were normal. She was still unable to void. One ounce of castor oil was administered by mouth and four hours later there was a copious bowel movement with a reduction in the distention, and an almost complete relief of pain. One hour later, and for the first time since delivery, the patient vomited some undigested food. By 9:30 P.M. the distention had recurred and a consultation was requested from the surgical service of the U. 8. Naval Hospital. Paralytic ileus and partial mechanical obstruction were considered to be tentative diagnoses. The patient was still afebrile ; pulse rate of 80. Wangensteen suction was instituted and three units of plasma administered. A flat plate of the abdomen taken on the morning of the third postpartum day was not entirely satisfactory because of gaseous distention, but it revealed a large bowel distention with no definite point of obstruction. Examination of the abdomen showed some visible peristalsis. Five hundred cc. of titrated blood were administered. Following this the patient had a chill and temperature elevation to 103.5O F. Temperature returned to normal four hours later and the supposition was that the chill and fever represented a transfusion reaction. Distention remained moderate throughout the day. On the morning of the fourth post-partum day, the distention was definitely accentuated, the abdomen was tender, no peristalsis could be discerned by auscultation and the patient’s condition was obviously more critical. Temperature was mildly elevated and the pulse rate was increased. At 2 :OO P.M. on the fourth postpartum day, operation was done under continuous spinal anesthesia. The abdomen was entered through a small left reetus incision revealing a hyperemic peritoneum and an increase in intraperitoneal fluid. A huge sausage-shaped mass could be felt extending obliquely upward and to the left across the abdomen. As the incision was enlarged, a volvulus of the eecum and lower portion of the ascending colon spontaneously delivered itself. The mesocolon was edematous and definitely elongated and the bowel had rotated counterclockwise, allowing the cecum to occupy a position beneath the left lobe of the liver. The bowel was dusky, there were some breaks in the serosa, but no evidence of devitalization. Reduction of the volvulus was easily accomplished and cecostomy was performed, the cecostomy tube being carried out through a stab wound in the right lower quadrant. The abdomen was closed without drainage after the introduction of five grams of sulf athiazole crystals. Three units of plasma were given and the immediate postoperative condition was excellent.
270
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
Wangensteen drainage was continued. Intravenous sodium sulfathiazole was administered at eight-hour intervals, and plasma, &rated blood, and intravenous glucose sohnion were given. The patient was irrational on the first and second postoperative days. There was a mild jaundice which was thought to be hemolytic and associated with the transfusions. Maximum temperature elevation reached 103.4O F. The Wangensteen tube was removed on the third postoperative day, and the colostomy tube and all sutures were removed by the fourteenth postoperative day. The patient was discharged from the hospital on the twentieth postoperative, or the twenty-fourth post-partum day. Her bowel habits had been normal for one week at the time of her discharge. This case constitutes an unusual complication following a normal delivery. We feel that delivery with the sudden emptying of the uterus was a contributory factor. A partial obstruction probably existed from the time shortly following delivery, becoming complete on the evening of the third post-partum day. It is conceivable that an exact diagnosis could have been arrived at preoperatively, and surgical intervention instituted at an earlier date.