A rare cause of bowel obstruction in pregnancy
A 30-year-old primigravid Caucasian female presented at 38 weeks and 3 days gestation with 24-h of abdominal pain, nausea and vomiting. She continued to pass flatus and had opened her bowels the day before. Past medical history included polycystic ovarian syndrome and right donor hepatectomy 6 years prior in a living-related liver transplant. She took no regular medications, had no allergies and did not smoke or drink alcohol.\nOn assessment, she appeared to be uncomfortable and had a tympanitic abdomen, which was generally tender but soft to palpation with scant bowel sounds. Vital signs were normal and fundal height was appropriate for gestational age. A ‘Mercedes-Benz’ scar was seen (a Chevron incision extended up to the xiphoid), consistent with previous liver surgery. Urinalysis was negative for infection, pelvic examination was unremarkable and cardiotocography showed a reassuring foetal trace. Rectal examination showed an empty vault with no masses and was negative for occult blood.\nLaboratory investigations revealed a high normal white cell count (16 × 109/l, reference range for pregnancy 5.9–16.9) with mild neutrophilia (14.4 × 109/l, normal 3.9–13.1). Haemoglobin, electrolytes, renal and liver function tests and lactate were normal.\nProvisional diagnosis of adhesive partial small bowel obstruction was made. A nasogastric tube was inserted, affording marginal symptomatic relief. Rectal enema was unsuccessful. Plain radiography showed colonic faecal loading with superolateral displacement of bowel loops by the gravid uterus, without evidence of obstruction or free sub-diaphragmatic air. Ultrasound showed a viable foetus with no specific intra-abdominal pathology.\nIncreasing analgesic and antiemetic requirements prompted induction of labour at 38 weeks and 4 days gestation, with vaginal delivery of a baby boy. Despite clinical improvement initially, symptoms worsened again 24 h postpartum. She was no longer passing flatus and there were no audible bowel sounds. Repeat abdominal radiograph showed a large bowel obstruction with caecal dilatation up to 13 cm (Figures and ). The small bowel was also dilated, up to 5 cm.\nThe patient was brought to the operating theatre for midline laparotomy. Large volume ascites was encountered and several small bowel adhesions divided. A transition point was identified in the right upper quadrant, with incarceration of omentum and colon through a 2 cm defect in the posterolateral right hemidiaphragm, producing a Richter's hernia. The defect was extended to facilitate reduction of the hernial contents. The herniated omentum was necrotic, but the large bowel appeared viable. The defect was closed with interrupted figure-of-eight 0-Ethibond sutures (Johnson and Johnson). A 14-French Foley catheter was placed into the pleural space through the diaphragmatic defect and slowly withdrawn on suction as the diaphragmatic sutures were tightened to prevent pneumothorax.\nThe patient's symptoms resolved postoperatively and mother and baby discharged home on the seventh postoperative day. Retrospective review of the preoperative erect chest X-ray showed a knuckle of herniated colon was in fact visible above the diaphragm (Figure ).