Bowel obstruction and pregnancy

Under normal conditions, the strangulation of the bowel during pregnancy does not occur, despite of increase of volume of the uterus and displacement of the internal organs. Bowel mobility and the possibility of significant changes of the gut clearance allow to adapt to the new conditions arising during pregnancy. Therefore, the cases of bowel obstruction during pregnancy are rare. The disease incidence of ileus - 1 to 50000 delivery. In Russian literature the first case described I. M. Tarnowski in 1877, and A. P. Ioffe (clinic of Professor A. E. Mandelstam) in 1933 collected 214 observations.
Pregnant or postpartum uterus itself may not be the root cause of this complication; otherwise, intestinal obstruction during pregnancy met would be much more often. Bowel obstruction occurs usually in the presence of adhesions and cicatrices, scars, formed after surgery or inflammatory processes, elongated mesentery, tumors, etc p.; significantly less likely to cause obstruction are intussusception and hernia.
During pregnancy there are three periods that are critical in the sense of the possibilities of development of intestinal obstruction:
1) output of the uterus cavity, small pelvis up (3-4th month of pregnancy);
2) lowering the head of the fetus at the end of pregnancy;
3) the sudden reduction of the uterus after delivery S. rapid change intrauterine pressure.
During these periods occur more often inversions, kinks, and the strangulation of the bowel, because it is easier happen offset and shifts the latter. Due to the strangulation of the bowel gravid uterus leading plot ulcer, having met an obstacle twisted around its axis; however, it is difficult to imagine that a bowel obstruction called only by the tumor from outside of the uterus. It appears that in some cases the occurrence of intestinal obstruction due to the lowering his tone, and in this regard upset motor function of the latter. The reason for the reduction in tone (paresis smooth muscles) is, apparently, infection or intoxication on the grounds of toxemia of pregnancy or acute disease in the abdomen, which is inevitably associated violation of the functional state of the Central nervous system.
Accordingly reasons that causes intestinal obstruction, we can talk about strangulation, obstructive and dynamic form of obstruction (Fig. 70 and 71). When strangulation obstruction there is an explicit mechanical reason for not only blockage or compression of the bowel lumen, but the disorder of blood circulation and nutrition of the affected area of the colon. In obstructive ileus is only a blockage of the bowel lumen, without eating disorders of the intestinal wall; after the long-term stasis later may come malnutrition affected area of the colon. Dynamic form, which is not marked change from the gut wall and its mesentery, conditioned or paralysis, or spasm of the intestine.


Fig. 70. Inversion of the lower segment of the small intestine (at 300 degrees).

Fig. 71. Strangulation obstruction. Infringement by the band.

The recognition. To recognize bowel obstruction during pregnancy is very difficult. Often, especially in the later pregnancy, obstruction mixed with the outbreak of birth (observation N. Century Sudakov, M. of Naiditsch and others), and only careful observation of pregnant woman finds out whether the bout. The tension of the abdominal wall and a sharp pain when you touch don't allow to define the contours of the uterus and thus check whether labor activity.
Therefore the characteristic little evidence. Only vaginal examination can resolve the issue, there began labor activity or cramping pain is a result of obstruction of the bowel.
Recognition of intestinal obstruction easier during pregnancy for up to 6-7 months, as other related complications (cyst, adhesions, scars) often make themselves known, long before significant increase of the volume of the uterus (M. S. Naiditsch). Intestinal obstruction of pregnancy and develops tumors acute; when exudates, opposite, slowly, gradually. Careful observation, otherwise bowel obstruction in a timely manner may not be recognized, resulting in operational assistance may be delayed.
Early symptom of inversion - persistent constipation is often viewed as pregnant women often suffer from constipation. The main signs of bowel obstruction are: sharp increase in the volume of the stomach, the strong expansion of the leading segment of the colon, persistent violation of the functions of the intestine, delayed discharge of gases. Vomiting is a relative value, although it happens more often than usual in childbirth. Vomit is not always a brown colour and fecal odor. Vomiting feces is only clinically severe cases, when it come gangrene of the bowel. Patients then observed fades hippocratica, the sharp weakening of cardiac activity and increasing collapse.
In intussusception marked a sharp change in the General situation of the patient, growing for several hours; frequent vomiting, pulse becomes frequent and weak filling, blown up by the intestines and appears defense musculaire, the body temperature rises relatively few. In advanced cases of obstruction comes peritonitis with all its symptoms.
Differential diagnosis should be deleted attacks of pain associated with the passage of stones through the ureter or through the ductus choledochus, pielit, uncontrollable vomiting, ectopic pregnancy.
The forecast. The prediction is very serious. The mortality rate is quite high (I. Rusin, M. S. Naiditsch and others), significantly higher than outside of pregnancy. In recent years postoperative mortality was significantly reduced, which could be brought into relationship with the improved diagnosis, earlier hospitalization and timely undertaken by the operation, as well as the widely used blood transfusions, parenteral protein diet (hydrolysis - L-103 and so on), lumbar procaine blockade, antibiotics, etc.
For the development of obstruction of the age of the woman, apparently, does not matter. As the number of previous pregnancies, then perhaps this is important for those women who have lethargy abdominals and availability venter propendens.
Acute intestinal obstruction usually found on the 5-6th month of pregnancy, but more often at the end of the last and the time of delivery.
In the postpartum period bowel obstruction occurs more frequently than during pregnancy and childbirth.